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JS-55A3 (New 10/2007


Circle Month:
Retirement Jul. Aug. Sep. Oct. Nov. Dec. Year
Name SSN
To remain eligible for Trade Readjustment Allowances (TRA) and claim the Health Coverage Tax Credit (HCTC) as a TAA
recipient after the applicable training enrollment or waiver deadline, a worker who has not completed Trade Act-approved
training must either be enrolled in such training or covered by a waiver of the training requirement (prior to the deadline,
no waiver or training enrollment is required). Federal Trade Act regulations require that all training waivers be reviewed at
least every 30 days to determine if the conditions existing at the time of waiver issuance continue to exist. In the event
conditions have changed and training becomes feasible and appropriate, the waiver must be revoked. Failure to comply
with the monthly waiver review process will result in waiver revocation and jeopardize your eligibility for TRA and HCTC.
Directions: Complete and return this form on the first fifteenth of each month as directed by your Labor
Department career development specialist. The form must be received within ten days of the due date. Begin
with the month following waiver issuance.

Section One - Job Search Review
How many employers did you contact during the past month?
0 1-5 6-11 12-15 16-19 20 or more
If you did not actively seek work during the past month, explain why and skip any remaining questions in
this section that do not apply.

How did you find most job leads during the past month? Check all that apply.
Job/Career Fairs Online Job Sites/Job Boards CT Department of Labor Referral
Networking Cold Contact/Direct Mail College Career/Alumni Offices
Help Wanted Signs Recruiters/Headhunters Professional/Trade Organizations
Union Hiring Halls Corporate Career Centers Want Ads/Newspaper Websites
How did you seek work during the past month? Check what was most typical.
I made phone calls. I submitted applications. I inquired or applied in person.
I applied online. I was interviewed. I submitted copies of my resume.
I made inquiries asking if any jobs were available. I applied for specific positions.
How many interviews did you have during the past month? 0 1 2 3 4 5 or more
Compared to prior months, is the number of interviews
increasing? decreasing? remaining steady?
Were any of your interviews “second” or “third” interviews? Yes No
If you have not yet been offered a job, what reason(s), if any, have employers given you for not being
selected? What feedback have you received from employers about your qualifications? If you have been
advised that you lack any particular qualification(s), please indicate.

If you know of anything else that may be preventing you from finding work, please indicate.

Are you running out of employers to contact for suitable job opportunities? Yes No
If you have started to seek work that is less desirable than your past job, indicate how these job
opportunities compare. If necessary, provide additional details in the comments section on page two.
Lower Wages Lower Skill Fewer Fringe Benefits Less Desirable Shift Fewer Hours
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Section Two - Employment Status
I am currently unemployed. I am working as previously reported.
During the past month, I accepted work that is:
full-time part-time and temporary permanent.

Employer: Start date:
Title: Pay rate: $ per
If not working, what is your chance of being offered a job during the next month?
Poor Fair Good Excellent
Do you request an in-person appointment with a career development specialist (if not already scheduled)?
Yes No If yes, indicate any weekdays you are not available during the next month.

IMPORTANT: This monthly waiver review is conducted to determine your ongoing eligibility for a Trade Act training
waiver. Providing information here DOES NOT satisfy the reporting requirements of Unemployment Insurance (UI)
or TRA claims in the case of questions about circumstances “not previously reported.” Information provided here
about any job refusals or change in your employment or work availability status must also be given when answering
similar questions on your weekly claims.

Section Three - Waiver Review
You received a training waiver based on meeting -- or being within two years of meeting -- requirements for
entitlement to either social security benefits or a private pension.
Indicate the estimated amount of time you plan to remain attached to the labor market.
Less than two years Two to four years Five years or longer
Is this a change from what you previously indicated? Yes No
If there has been a change in your circumstances:
Do you have an interest in training? Yes No If yes, what kind of training?

In order to qualify for additional TRA if otherwise eligible, you must sign a bona fide application for training
Note TRA within 210 days of either the date of the Trade Act certification providing your eligibility or the date of your
Deadline: most recent qualifying separation, whichever is later. In Connecticut, a bona fide application for training is
the JS-52/Trade Adjustment Assistance (TAA) Training Application and Proposal.
If you believe you may qualify for a training waiver based on one of the other five criteria, check the
appropriate category and explain below.
Recall Marketable Skills Health Enrollment Unavailable Training Not Available

I certify that the information I have provided is true and correct to the best of my knowledge and belief. I understand that
the reporting of any job refusals or change in my employment or work availability status here DOES NOT relieve me of
my obligation to fully disclose similar information requested of me during the filing of my weekly UI or TRA claims, unless
expressly authorized by a Labor Department representative.
Signature Date
Phone Email JS-55A3

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