You are on page 1of 1

Connecticut Department of Labor

ATAA – APP (REV. 11/05) IMPORTANTE - TENGA ESTO TRADUCIDO
INMEDIATAMENTE
CONNECTICUT DEPARTMENT OF LABOR
Alternative Trade Adjustment Assistance (ATAA) Individual Application Petition#

Applicant’s Name SS#
Mailing Address Telephone #
City State Zip Date of Birth
TAA Certified Employment (please provide payroll check stub)
Name of Firm/Division: Last Day Worked:

Hourly Rate for the Last Full Week of Work: # of Hours Worked (include sick & vacation time) Last Full Week of Work:

New Employment
Name of Firm/Division: UI TAX ID #

Mailing Address Phone #

City State Zip

Contact Person: Start Work Date:

Hourly Rate for the First Full Week of Reemployment:

How many hours in a Standard Full-Time Work Week?

# of Hours Worked (include sick & vacation time) First Full Week of Reemployment:

PAYROLL PERIOD FROM: TO :
NEW EMPLOYER’S SIGNATURE IS ONLY REQUIRED FOR THOSE APPLICANTS WHO DO NOT HAVE A PAYCHECK AS OF THE DATE OF THIS FORM.
I attest as the above-named NEW employer’s representative that the above-named applicant will earn $50,000 or less in the 12-month
period beginning with the initial date of employment and that he/she meets the definition of reemployment as defined in #4 and #5
below. Additionally, I verify that the above information is true and accurate.

Employer Representative’s Printed Name/Title

Signature Date

For the Applicant:
You must meet with your Trade Act representative to submit this application and other ATAA forms. Trade-impacted workers
must be covered by a Trade Adjustment Assistance (TAA) certification and certified as eligible to apply for ATAA. At the time of
reemployment, the following conditions must also be met:
1. You were at least age 50 at the time of reemployment. (Verify with copy of driver’s license or birth certificate.)
2. You were reemployed within 26 weeks of your qualifying separation. (Verify with copy of job offer letter, paycheck stub or
statement from employer. See New Employment section above for employer statement and signature.)
3. You will be earning $50,000 or less per year in wages from reemployment. (Verify with copy of paycheck stub or
statement from employer. See New Employment section above for employer statement and signature.)
4. You will be reemployed for 35 hours or more per week. NOTE: Employment may be with more than one employer.
A separate application must be submitted for each employer. Wages from all employers must be reported.
5. You did not return to the employment from which you separated. This does not preclude returning to a different job with
the same employer in a different division or facility.
STATEMENT: I hereby attest that the facts given above are true and correct. In accordance with Section 241 of the Trade Act of
1974 as amended by the Trade Act of 2002, I hereby request consideration for certification of individual eligibility under the
Alternative Trade Adjustment Assistance Program (ATAA). By signing this form I UNDERSTAND THAT RECEIPT OF MY FIRST
PAYMENT UNDER THE ATAA PROGRAM VOIDS MY RIGHTS TO TAA TRAINING, JOB SEARCH ALLOWANCES AND TRADE
READJUSTMENT ALLOWANCES AS STATED IN SECTION 241. I UNDERSTAND THAT PENALTIES ARE PROVIDED FOR WILFUL
MISREPRESENTATION MADE TO OBTAIN ATAA BENEFITS TO WHICH I AM NOT ENTITLED.

Applicant’s Signature Date

Signature of TAA Representative: Date Application Received