Reconciliation of Trade Out-of-Area Job Search Allowance
Customer Information2002 - TAA Petition Requirements (60,000 - 69,999 or 80,000 - 80,999, as applicable) / 2009 - TGAAA Petition Requirements (70,000 - 79,999) / 2015 - TAARA Petition Requirements (85,000 and above)
1. LWIA #/ETC: / 2. Customer SSN: XXX-XX- / 3. Reconciliation Date: //
4. Customer Last Name: / First Name: / Middle Initial:
5. Street Address (Residence): / Apt.:
6. City: / 7. State: / 8. Zip:
Trade Out-of-Area Job Search Information
9. Trade Petition Number: / 10. Interview Date: //11. Name of Company: / 12. Title Applied for:
13. Contact Name: / 14. Phone Number: ()-; ext.
15. Street Address (location of interview): / PO Box:
16. City: / 17. State: / 18. Zip:-
Trade Out-of-Area Job Search Payment Eligibility
19. The Trade Out-of-Area Job Search was completed. / Yes No20. The Trade Out-of-Area Job Search was completed within 30 days of the beginning of the Job Search. / Yes No
21. There is verification of employer contacts certified by the LWIA. / Yes No
22. Travel associated with the Out-of-Area Job Search was for more than 12 hours. If No, the customer is not eligible for Subsistence Assistance. Do not complete Items #33-#37 below. / Yes No
23. Approved Denied / If Yes is answered to #19 - #21 above, Trade Out-of-Area Job Search Allowance shall be approved.
If denied for reasons other than #19 - #21 above, describe the reason:
If Denied, proceed to Item #45.
Trade Out-of-Area Job Search Allowance Reconciliation
24. Previous Allowance Payments / 25. Available Allowance Calculation:Date / Amount / (a) Maximum Job Search Allowance ($1,250 or $1,500)
(b) Previous Job Search Payments (Item # 24e):
(c) Remaining Job Search Allowance (#25b from #25a): / $
$
$
(a) //
(b) //
(c) //
(d) additional payments*:
(e) Total All Previous Job Search Payments: / $
$
$
$
$
Note: The maximum Trade Out-of-Area Job Search Allowance is $1,250 for TAA and TAARA or $1,500 for TGAAA. The customer may conduct multiple Job Searches to reach the full benefit amount. The customer is only eligible to receive an Out-of-Area Job Search Allowance up to the total of Item #25c. If the total in #25c is $0, the customer is not eligible to receive further Trade Out-of-Area Job Search Allowances. Skip to Item # 45.
* Provide listing of additional payments on a separate sheet.
Actual Trade Out-of-Area Job Search Allowance
Transportation Request: For current mileage rate, go to www.gsa.gov.26. Date / 27. Departed From / 28. Arrived
At / 29. Transportation / 30. Other Travel Expenses
(Tolls, parking, etc.) / 31. Line Totals
Auto Reimbursement
Miles X Rate = Compensation / Other
Mode* / Most Cost Effective Mode
Place / Time / Place / Time / Item* / Amount
// / X $ = $ / $ / $ / $ / $
// / X $ = $ / $ / $ / $ / $
// / X $ = $ / $ / $ / $ / $
// / X $ = $ / $ / $ / $ / $
*Note: Describe here the Other Mode of Transportation and "Other" Travel Expenses anticipated to be incurred: / 32. Total: $
Subsistence Request: For the current per diem rate go to www.gsa.gov.
33. Date / 34. Lodging and Meals Expense / 35. GSA Per Diem Rate / 36. Most Cost Effective
a. Lodging / b. Meals / c. Total Lodging & Meals / a. Maximum GSA Per Diem rate / b. 50% of
Per Diem
// / $ / $ / $ / $ / $ / $
// / $ / $ / $ / $ / $ / $
37. Total Most Cost Effective: / $
38. Lodging Information (* Provide additional Lodging Information on a separate sheet)
Name:
Address:
City: / State: / Zip:
Phone: () -, ext. / Fax: () -
39. Trade Out-of-Area Job Search Allowance Expenses (Items #32 + #37): / $
40. Allowable Out-of-Area Job Search Allowances (#39 X 90% for TAA and 2015 TAARA or 100% for TGAAA) / $
41. Requested Trade Out-of Area Job Search Allowance (Lesser of Items #25c or #40) / $
42. Was the Customer provided an Advance Payment of their Out-of-Area Job Search Allowance? Yes No / 43. If Yes to Item #42, indicate Amount: $
44. Difference Owed to Customer (Item #43 from #41) :$
45. I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud. Furthermore, I understand that falsifying information or using the funds other than for the intended purpose is felony theft and is punishable under state law by up to 7 years in prison and fines of up to $25,000. Violators may also face federal felony charges.
I understand that I am not eligible for the Trade Out-of-Area Job Search Allowance requested and this form serves as my written notification of such determination.
46. Customer Signature: / Date: //
APPEAL RIGHTS
If you disagree with this determination, you may complete and submit a request for reconsideration/appeal. A letter will suffice if you do not have an agency form. Your request must be filed with the Illinois Department of Employment Security (“IDES”) within thirty (30) calendar days after the date at the top of this letter. If the last day for filing your request is a day that IDES is closed, the request may be filed on the next day that IDES is open. Please file the request by mail or fax at your local IDES office. To locate your reporting office, use this link: http://www.ides.illinois.gov/Pages/Office_Locator.aspx.
Any request submitted by mail must bear a postmark date within the applicable time limit for filing. If additional information or assistance regarding the appeals process is needed, please contact your local IDES office.
STAFF USE ONLY
AFFIDAVIT
I certify that the preceding information is correct to the best of my knowledge and that there is no intent to commit fraud. I hereby acknowledge that the information contained in this form that I am attesting to is complete and accurate and that the documentation described in the form is contained in the customer's file.
47. Career Planner Signature: / Date: //
48. LWIA Director Signature: / Date: //
NOTE: THE LWIA CAREER PLANNER SHALL NOT RELEASE REIMBURSEMENT PAYMENT UNTIL THEY HAVE RECEIVED A COPY OF THE LETTER/FORM (Commerce/Trade Form # 012b, #012c or #012d) FROM THE INTERVIEWING COMPANY(S) OR LWIA REPRESENTATIVE VERIFYING THE CUSTOMER HAS COMPLETED ALL JOB SEARCHES.
July 19, 2017 Page 2 of 2 Commerce/Trade Form #012a