TAA-855 (Rev 4/14)
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.
Be certain to sign the certification section at the bottom of the second page. Return to: Connecticut Department of Labor,
Unemployment Insurance Technical Unit, 200 Folly Brook Blvd., Wethersfield, CT 06109 or fax to (860) 263-6039.
Petition Number
Applicant’s Name (Last, First, Middle Initial)
Social Security Number
-
Mailing Address (Number, Street)
Date of Birth
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.
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
Type of separation:
Total
Partial - still employed part-time, working
Other
hours per week.
Answer if you have not yet separated, but have received a notice of future termination or layoff due to lack of work:
What is the nature of the expected separation:
total
partial (reduction in wages and hours)
When is the separation expected to occur?
How and when were you notified?
Indicate the name, title and phone number of the company official who notified you about your upcoming separation
or attach documentation, if available.
Have you received benefits under a prior TAA Certification in the past ten years?
Yes
No
Subsequent Employment
Did you perform work after separating from your trade-impacted employment (include self-employment)?
Yes
No
If yes, complete remainder of this section.
Name of Employer
Start date
Are you currently employed? Yes
If no, indicate last day of work:
No
Full time
Part time
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.
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:
Veteran Status
Section 2(a) of the Jobs for Veterans Act, P.L. 107-288 (38 USC 4215(a)), creates a priority of service for veterans and some
spouses who otherwise meet the eligibility requirements for participation in Department of Labor training programs, including
Trade Adjustment Assistance. Check applicable box.
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.
If, as a member of a reserve component of the Armed Forces, you were required to interrupt or postpone employment-related
assistance, including Trade Act benefits, indicate whether either of the following is true and provide your dates of service.
I served on active duty for a period of more than 30 days under a call or order to active duty of more than 30 days. I was
engaged in such service from _________ to _________.
As a member of the Army National Guard of the United States or Air National Guard of the United States, I performed fulltime National Guard duty under 32 U.S.C. 502(f) (regarding required drills and field exercises) for 30 consecutive days or
more when authorized by the President or the Secretary of Defense for the purpose of responding to a national emergency
declared by the President and supported by Federal funds. I was engaged in such service from _________ to _________.
Explanation of TRA Benefit Deadlines
To receive Trade Readjustment Allowances (TRA), an otherwise eligible individual must enroll in or complete training approved
under the Trade Act, or receive a waiver of this training requirement, within a specified period of time:
 For petition numbers between 70000 and 79999, and 81,000 -84,999 (2011 requirements), within 26 weeks of one of the
following, whichever is later: 1) the petition certification date, or 2) the week of the individual’s most recent qualifying
separation date. (also referred to as the “26/26” deadline)
 For petition numbers less than 70000 & greater than 85,000: within either 8 weeks from the petition certification date, or
within 16 weeks from the individual’s most recent qualifying separation, whichever is later. (the “8/16” deadline)
 For petition numbers between 80,000 through 80,999 the TRA training deadline could be either “8/16” or “26/26” :
individuals who received TAA benefits and made no election to switch to the 2011 requirements by 3/19/12 are under the
“8/16” deadline rule; individuals who did not receive TAA benefits, or, who received TAA benefits but opted to switch to the
2011 requirements are under the “26/26” rule.
If extenuating circumstances justify a delay in the training enrollment period, the deadline may be extended by 45 days.
Extensions beyond 45 days may be possible under certain circumstances and based on your petition number.
If your applicable training enrollment deadline is within 30 days or has already passed, complete this section.
If you did not receive this application directly from the Connecticut Department of Labor, how and when did you first learn about
your eligibility to apply for Trade Act benefits?
If you received a Trade Act application from the Connecticut Department of Labor but are applying late for personal reasons,
explain the reason(s) for your delay (attach a separate sheet of paper if necessary).
Certification
I certify that all statements made on this document are true and complete to the best of my knowledge and belief. I have been advised
about the TRA training enrollment deadline, as described in the section above, and 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