UI / DE 8309A

SAMPLE, this page for reference only

 
Special Claims Office 850 • P.O. Box 269058 • Sacramento, CA 95826-9058

AFFIDAVIT FOR TRADE ADJUSTMENT ASSISTANCE (TAA)

For Office Use Only
Blank Line
Name
Blank Line
Petition No.
Blank Line
Impact Date
Blank Line
The Employment Development Department (EDD) is unable to obtain sufficient information regarding your employment from the adversely affected employer in order to complete the determination of your eligibility. Therefore, please provide information about your employment with the adversely affected employer.
Employer’s NameBlank space Sub-divisionBlank space
Employer's Address (No., Street, City, State of site where worked)Blank space

A. SEPARATION INFORMATION
List date and information regarding each separation on or after impact date.
(1) Date (2) Department/Division from which Separated (3) Reason for Separation (4) Date returned To work (if applicable) (5) During how many 52 calendar weeks before each week listed In Column 1 did you work and earn at least $30 in adversely affected employment
Blank space  Blank space  Blank space  Blank space  Blank space 
Blank space  Blank space  Blank space  Blank space  Blank space 
Blank space  Blank space  Blank space  Blank space  Blank space 
Blank space  Blank space  Blank space  Blank space  Blank space 
6.
If you did not work at least 26 weeks and earn at least $30 in each of those weeks in any of the 52 weeks prior to at least one of your separation dates, did you have any weeks of paid sick leave, vacation, military leave and/or full time leave as a representative for a labor organization? If so, how many weeks? Blank Line__________________.
7.
How many weeks did you receive Workers’ Compensation benefits? Blank Line__________________.

B. WORKER AFFIDAVIT
As proof of the information provided in this request, I offer the following evidence:
List documents
Blank Line
Blank Line
 
Blank Line
Blank Line
 
Blank Line
Blank Line
I understand that any claim established on the basis of my statement and on the evidence I have provided may be subject to correction if contradictory facts are received at a later date. I also understand that penalties are provided for willful misrepresentation to obtain allowances to which I am not entitled.
Signature of Worker:
Blank line  
Date Signed:
Blank line  

C. DEPARTMENT VERIFICATION
As a representative of EDD, I have examined the documents listed above in B. Based on this evidence (copies attached), the entries appear to be correct.
Signature of Interviewer:
Blank line  
Telephone No.:
Blank line  
FO No.:
Blank line  
Date:
Blank line  
DE 8309A Rev. 3 (10-21) (INTRANET)