UI / DE 8309

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 

APPLICATION FOR TRADE ADJUSTMENT ASSISTANCE (TAA)
Complete all items in Sections A through D
Mail to:
SPECIAL CLAIMS OFFICE TRA STATE OF CALIFORNIA EMPLOYMENT DEVELOPMENT DEPARTMENT PO BOX 419076 RANCHO CORDOVA, CA 95741-9076
SECTION E: Department Use - TAA Certification Information
Petition No:
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Impact Date:
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Certification Date:
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Termination Date:
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SECTION A: Worker Information
Social Security Number
XXX-XX-Blank space		 Name (First)Blank space (MI)Blank space (Last)Blank space BirthdateBlank space
Your Mailing AddressBlank space Apt.Blank space CityBlank space StateBlank space ZipBlank space
Phone Number Where You Can be Reached (
 
) Blank Space
SECTION B: Employment Information
Name of Affected EmployerBlank space Subdivision or DepartmentBlank space Type of Work You DidBlank space
Employer’s Mailing AddressBlank space CityBlank space StateBlank space ZipBlank space
Date of First Separation from Affected EmploymentBlank space Reason for SeparationBlank space
Dates of Subsequent Separations Reasons for Separations
1Blank space 1Blank space
2Blank space 2Blank space
3Blank space 3Blank space
SECTION C: Other Eligibility Information Yes No Explain All "Yes" Answers
1.Have you worked for any employer since your separation from the employer shown in B above? Employer NameBlank space
Date Began WorkBlank Space AddressBlank Space
Date of SeparationBlank Space Reason for SeparationBlank Space
2. Have you filed an application for TAA prior to this application? State Where FiledBlank space Date FiledBlank space
3.Have you filed a claim for Unemployment Insurance benefits since your separation from the affected employer? Paying StateBlank space
Name of ProgramBlank space
4. How did you learn of the certification?Blank space
SECTION D: Worker’s Certification
I have answered these questions for the purpose of applying for TAA benefits, knowing that the law provides penalties for making false statements.
Signature of Worker:
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Date Signed:
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SECTION F: Department Use - Field Office TAA specialists -Document Incumbent Worker requests for TAA pre-separation training. Worker must complete Section A – D, excluding separation information.
Documentation Supporting Worker Threatened With Layoff/Termination From Affected Employment
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Employer Contact Name
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Employer Contact Phone Number
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Employer Contact Fax Number
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Date of Initial Contact (On or After Cert Date)
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Expected Separation Date
Interviewer Signature:
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Date Signed:
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F.O. #
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DE 8309 Rev. 7 (10-21) (INTERNET)