ALTERNATIVE TRADE ADJUSTMENT ASSISTANCE (ATAA) WAGE SUBSIDY REQUEST FORM

Name:

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Social Security Number:

‎‎XXX-XX-Blank space

If your mailing address or telephone number has changed, print correction:

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Phone Number:Blank space

Caption
Question
	Week ending dates
	1st week		2nd week
1. I AM CLAIMING ATAA WAGE SUBSIDY BENEFITS FOR THE CALENDAR WEEKS ENDING SATURDAY:	Blank space		Blank space
2. DID YOU WORK FULL TIME: (IF NO, EXPLAIN WHY IN THE “REMARKS” SECTION BELOW)	Yes	No	Yes	No
3. WERE YOU PHYSICALLY ABLE AND AVAILABLE FOR WORK EACH DAY? (IF NO, PLEASE EXPLAIN IN THE “REMARKS” SECTION BELOW)
4. HOW MANY HOURS DID YOU WORK EACH WEEK?	Blank Line		Blank Line
5.WHAT WERE YOUR GROSS EARNINGS? (Enter earnings before deductions, WHETHER YOU WERE PAID OR NOT: include holiday and any vacation pay.)	$ Blank Line gross amount		$ Blank Line gross amount

6. IF NOT SCHEDULED TO WORK AFTER WEEKS CLAIMED, SHOW REASON:

LACK OF WORK WORKING ON CALL QUIT FIRED

7. HAVE YOU CHANGED EMPLOYERS SINCE YOU STARTED ATAA?YES NO

IF YES, ENTER START DATE FOR NEW EMPLOYER: Blank Line NOTE: YOU MUST REAPPLY FOR THE ATAA PROGRAM.

I HEREBY CERTIFY THAT ALL THE INFORMATION I HAVE PROVIDED IS ACCURATE. I UNDERSTAND THAT PENALTIES ARE PROVIDED FOR WILLFUL MISREPRESENTATION MADE TO OBTAIN ALLOWANCES TO WHICH I AM NOT ENTITLED.

REMARKS:

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Signature

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Date Signed

MAIL COMPLETED FORM TO:

EDD SCO 850 TAA-ATAA PO BOX 419076 Rancho Cordova, CA 95741-9076 Telephone number ‎1 (888) 697-1760

DE 8333 Rev. 2 (10-21) (INTRANET)

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ALTERNATIVE TRADE ADJUSTMENT ASSISTANCE (ATAA) WAGE SUBSIDY REQUEST FORM