UI / DE 8330

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

ALTERNATIVE TRADE ADJUSTMENT ASSISTANCE (ATAA) INDIVIDUAL APPLICATION

This application must be submitted within two years of an individual’s qualifying re-employment.
Worker’s Name:Blank space
Birth Date:Blank space
Social Security Number:
‎XXX-XX-Blank space
Worker’s Mailing Address:Blank space
NEW Employer(s) Name(s), Address(s),
Phone Number(s) and Contact(s):Blank space
Petition Number and Name of Previous Employer:Blank space
Date of Re-employment:Blank space
Estimated Annual Separation Wages:
  1. Hourly wage last week of full-time work before separation $Blank Line______________.
  2. Number of hours worked last week of full-time work before separation Blank Line______________.
Projected Annual Re-employment Wages:
  1. Hourly wage first week of full-time re-employment $Blank Line______________.
  2. Number of hours worked first week of full-time re-employment Blank Line ______________.
Current Employment: Signature of the NEW employer is only required for those workers who have not provided a pay stub or equivalent documentation of employment as of the date of this application. I attest that the above named worker is not expected to earn more than $50,000 in the 12-month period beginning with his or her initial date of employment.
Blank line 
NEW Employer Signature and Title
Blank line 
Date
NOTE: Documentation for estimated annual separation wages must also be provided. This may include check stubs, annual earnings statements, W-2 forms, or other official documentation.
STATEMENT:
I hereby request consideration for certification of individual eligibility under the Alternative Trade Adjustment Assistance (ATAA) Program. By signing this form, I understand that receipt of my first payment under the ATAA program voids my rights to retraining, job search and TRA benefits.
Blank line 
Signature of Worker
Blank line 
Date
MAIL COMPLETED APPLICATION TO:
‎EDD SCO 850 TAA-ATAA
P.O. Box 419076
‎Rancho Cordova, CA 95741-9076
Telephone Number: 1-888-697-1760

DE 8330 Rev.2 (3-22) (INTRANET)

SAMPLE, this page for reference only

Eligibility/Verification Requirements:

The following conditions must be met at the time of re-employment. Appropriate verification must be included with this application:
  1. Be at least age 50 at time of re-employment (verify with copy of drivers license or other official documentation);
  2. Re-employment within 26 weeks of qualifying separation (verify with a copy of the job offer letter or a check stub);
  3. Annual earnings from re-employment are not expected to exceed more than $50,000. (If a paycheck has not been issued at the time of application, then submit a supporting statement from the employer, in a company letterhead, indicating that annual wages are not expected to exceed $50,000.);
  4. Re-employed full-time (verified by pay stub, supporting letter from employer, or other appropriate documentation);
  5. Re-employment is new work, the worker cannot return to work from which the worker was separated. This means the worker cannot return to the same job in the same division/facility at the same company. It does not preclude a worker from obtaining a different job with the same employer (verified by pay stub, supporting letter from employer, or other appropriate documentation).

DE 8330 Rev.2 (3-22) (INTRANET)