TAA-855 (Rev.

7/2007) – 0073-855-01

Trade Adjustment Assistance - Request for Entitlement Determination

Connecticut Department of Labor – Employment Security Division
Trade Act of 1974, as amended

Instructions: Complete and return this application to apply for Trade Adjustment Assistance (TAA) benefits. Return to:
Connecticut Department of Labor Unemployment Insurance Technical Unit, 200 Folly Brook Blvd., Wethersfield, CT 06109.
Fax (860) 263-6039. Be certain to sign the certification section at the bottom of the second page.
Petition
Number
Applicant’s Name (Last, First, Middle Initial) Social Security Number
- -

Mailing Address (Number, Street)

City, State, Zip Phone Number

Do you require a language interpreter? Yes No If yes, please specify your

primary language. An interpreter will be provided at no cost to you.

Veteran Status
I served in the active U.S. military, naval, or air service for a period of less than or equal to 180 days, and was
discharged or released from such service under conditions other than dishonorable.
I served on active duty for a period of more than 180 days and was discharged or released with other than a
dishonorable discharge; or was discharged or released because of a service connected disability; or as a member of
a reserve component under an order to active duty, served on active duty during a period of war or in a campaign or
expedition for which a campaign badge is authorized and was discharged or released from such duty with other than
a dishonorable discharge.
I am (a) the spouse of a person who died on active duty or of a service-connected disability, (b) the spouse of any
member of the Armed Forces serving on active duty who at the time of application for TAA is listed in one or more of
the following categories and has been so listed for more than 90 days: (i) missing in action; (ii) captured in the line of
duty by a hostile force; or (iii) forcibly detained or interned in the line of duty by a foreign government or power; or (c)
the spouse of any person who has a total disability permanent in nature resulting from a service-connected disability
or the spouse of a veteran who died while a disability so evaluated was in existence.
None of the above.

Voluntary Release of Confidential TAA Information

I understand that my wage and unemployment insurance records that are maintained at the Connecticut Department of
Labor are protected under state and federal law, and that they cannot be disclosed to anyone outside of the Connecticut
Department of Labor, except to a public official in the course of his or her public duties, without my written consent.

To enable enhanced and efficient service delivery, I authorize the Connecticut Department of Labor to record and release
confidential information pertaining to my participation in the Trade Adjustment Assistance (TAA) program, e.g., training and
TAA benefit payment data and reemployment wages, to employment and training system partners (governmental agencies,
Workforce Investment Boards, and their subcontractors), for the purposes of program reporting, verification and
collaborative service delivery. Such information may be maintained in automated form on the Department’s CT Works
Business System (CTWBS).

I understand that I can revoke this authorization at any time, except to the extent that action has already been taken in
reliance on it. This authorization will expire twenty-four months after I have completed participation in the TAA or other
partner programs, e.g., Workforce Investment Act, Wagner-Peyser Act, and veterans workforce programs.

I am signing this form voluntarily, of my own free will. If I decide not to sign this release, I understand that my refusal to
release the information referenced above will not affect my eligibility to receive services.

Applicant’s Date
Signature
I refuse to authorize the release of TAA information as described above.
TAA-855 (Rev. 7/2007) – 0073-855-01

Trade-Impacted Employment
Name of firm/subdivision

Dates of employment
From To
Last department in which employed

Most recent job title

Complete address where work was performed

Reason for separation: Lack of work Discharge Voluntary leaving Other

Type of separation (check one) Total Partial - still employed part-time, working hours per
week
Subsequent Employment
Did you perform work after separating from the above (include self-employment)? Yes No
If yes, complete remainder of this section.
Name of Employer

Start date Are you currently employed? Yes No If no, indicate last day of work:

Address where work performed

Job title
Rate of pay $ per
If still employed, is this job of equal or greater skill level when compared to your trade-impacted
employment?
Yes No Why or why not? Compare job duties.

Full time Part time If temporary, expected end date: Reason for separation, if any:

Benefit Eligibility
Have you filed a request for a determination of entitlement to Trade Adjustment Assistance prior to this
application?
Yes No If yes, date filed: State in which filed:
Do you have entitlement to unemployment benefits? Yes No If yes, paying state:

Certification
I certify that all statements made on this document are true and complete to the best of my knowledge. I understand that to
be eligible for Trade Readjustment Allowance (TRA) I must have completed training approved under the Trade Act, be
enrolled in training or receive a waiver from this requirement by either the last day of the 16th week following the most
recent qualifying separation or the last day of the 8th week after the week in which the Secretary of Labor has issued a
certification, whichever is later. If the Administrator determines that there are extenuating circumstances that justify an
extension in the training enrollment period, the time limits described above may be extended for 45 days. I acknowledge
receiving a copy of form TAA-228, Trade Adjustment Assistance (TAA) / Trade Readjustment Allowances (TRA) Benefit
Rights and Responsibilities. I understand that penalties are provided for willful misrepresentation made to obtain
allowances to which I am not entitled.

Applicant’s Signature Date