Connecticut Department of Labor – Trade Adjustment Assistance (TAA)
Request for Relocation Allowances
Trade Act of 1974, as amendedName (Last, First, Middle) / Social Security No. / JobCenter / Date
Address / Petition No. / Company / Paying State
Date of total separation from adversely affected employment / Is this your first request for relocation allowance?
Basis for Relocation Allowance
Purpose: A relocation allowance shall be granted an adversely affected worker to assist the individual and the individual's family, if any, to relocate within the United States and outside the worker’s present commuting area. Application Requirements:An application may be submitted to a state agency at any time by an individual who has been totally or partially separated whether or not a certification covering the individual has been made; however, an application must be submitted to the state agency before the relocation begins for the relocation allowance to be granted, and the relocation may not be approved until after the individual is covered under a certification. The applicant must be totally separated from adversely affected employment at the time the relocation commences. Deadlines: A relocation allowance application may be approved only if submitted before (1) The 425th day after the date of the certification under which the individual is covered, or the 425th day after the date of the individual's last total separation, whichever is later; or (2) The 182nd day after the concluding date of Trade Act-approved training. Relocation must begin within 182 days of applying for relocation allowance or 182 days of concluding Trade Act-approved training. Relocation must be completed within a reasonable time, with consideration given to the availability of suitable housing in the area of relocation, whether the individual can dispose of his/her residence, whether the individual or a family member is ill; and whether a member of the individual’s family attending school would be best transferred to a school in the area of relocation at a future time. Verification:The state agency must verify with the employer that the individual has either obtained suitable employment affording a reasonable expectation of long-term employment, or a bona fide offer of such suitable employment, in the area of intended relocation. Amount Payable:The amount payable as a relocation allowance includes either 90 or 100 percent of the travel and moving expenses for the individual and family, if any, and a lump sum payment. The amount otherwise payable for travel and moving expenses shall be reduced by any amount the individual is entitled to receive as payment or reimbursement for such expenses from any other source. The reimbursement rate depends upon the applicable Trade Act certification.
Name and address of firm offering employment / Starting date / Job title
Name, address (if different from above), phone and email of the firm representative offering employment
If beginning work prior to relocation, please explain
Will you be entitled to receive payment or reimbursement for relocation expenses from this employer or any other source? If yes, indicate amount of reimbursement and provide full details on the reverse side. / Yes
No
Worker Request for Travel Allowance
Reimbursement rate: 90% if your petition number is lower than 70000 or greater than 80000; 100% if your petition number between 70000 and 79999.
Either 90 or 100 percent of the total costs ofthe more cost effective mode of transportation reasonably available and the cost allowable for lodging and meals while in travel status for you and your family, if any, from your place of residence to the area of relocation. If, for good cause, a member or members of your family must travel separately to your new residence, 90% or 100% of the total costs of such separate travel shall be included in calculating the total amount you are entitled to be paid. Good cause includes but is not limited to reasons related to the family member's health, schooling or economic circumstances. In no case may you be paid a travel allowance for yourself or a member of your family more than once in connection with a single relocation. No additional mileage shall be payable for family members traveling on the same trip in the same vehicle.
Travel dates, method and cost for worker and family members, if any / Travel dates / Auto / Commercial carrier
From / To / Mileage / Type / Cost
Number
Worker
Spouse
Children*
Other family members*
*Provide name, age and relationship of any children and other family members / Justification for the separate travel of family members
Name / Age / Relationship
Worker Request for Moving Allowance -Complete either section A, B or C and complete section D
Reimbursement rate: 90% if your petition number is lower than 70000 or greater than 80000; 100% if your petition number between 70000 and 79999.
Either 90 or 100 percent of the expenses of moving household goods and personal effects of yourself and family, if any, not to exceed the maximum number of pounds net weight authorized under the federal travel regulations (see 41 CFR Part 101-7), between such locations. Attach estimate(s) provided by the commercial carrier, trailer/truck rental agency and/or licensed insurer.
Section A. Cost Estimates for Commercial Carrier
Allowable costs for moving household goods and personal effects of yourself and family, if any, from your old residence to your new residence in the area of relocation, including reasonable and necessary accessorial charges, by the most economical commercial carrier you may reasonably be expected to use. Before undertaking such move, you must submit to the state agency an estimate from a commercial carrier as to the cost. Accessorial charges include the cost of insuring such goods and effects for their actual value or $10,000, whichever is least, against loss or damage in transit, if you obtain a bid from a licensed insurer that is approved by the state agency before departure. If more economical to pay a carrier an extra charge to assume the responsibility of a common carrier for such goods and effects, either 90 or 100 percent of such extra charge, but not exceeding $50, shall be paid in lieu of the cost of insurance.
Moving cost / $ / Insurance cost / $ / Other accessorial costs, if any / $
Section B. Cost Estimates for Trailer or Rental Truck
If household goods and personal effects are to be hauled by trailer / If to be hauled by rental truck
If the trailer is hauled by private vehicle, the cost per mile for the use of the private vehicle at the prevailing mileage rate authorized under the federal travel regulations (see 41 CFR Part 101-7) for the usually traveled route from your old residence to your new residence in the area of relocation, unless already covered by the allowance for travel, / $ / The rental fee for each day reasonably required to complete the move / $
AND
if the trailer is rented, the rental fee for each day reasonably required to complete the move / $ / The necessary fuel for such rental truck / $
If the trailer is hauled by a commercial carrier, the actual charge / $
Section C. Cost Estimates for House Trailer
If a house trailer or mobile home was used as your place of residence in the old area and will be so used in the new area
The commercial carrier's charges for moving the house trailer or mobile home / Charges for unblocking and re-blocking / Ferry charges, bridge, road, and tunnel tolls, taxes, fees fixed by a state or local authority for permits to transport the unit in or through its jurisdiction, and retention of necessary flagmen (provide breakdown on reverse side) / The cost of insuring the house trailer or mobile home, and the personal effects of yourself and family, against loss or damage in transit [in accordance with the provisions outlined in Section A.]
$ / $ / $ / $
Section D. Temporary Storage
If you will require temporary storage of household goods and personal effects, indicate number of days and total cost.
(Reimbursement covers up to 60 days.) / Number of days / Total cost / $ / Not applicable
Worker Request for Lump Sum Payment - Up to $1,250 if your petition number between 50000 and 69999 or greater than 80000; up to $1,500 if your petition number between 70000 and 79999.
A lump sum payment, equal to three times your average weekly wage, not to exceed applicable maximum. / Average weekly wage: / $ / Multiplied by three = / $
Worker and TAA Counselor Certifications
The information contained in this request is correct and complete to the best of my knowledge. I understand that penalties are provided for willful misrepresentation made to obtain allowances to which I am not entitled. I agree to certify amounts expended and provide all receipts requested by the state workforce agency and make restitution if the event allowances advanced to me exceed the amount to which I am entitled.
Worker’s Signature ______Date
The remainder must be completed by TAA counselor
Has the individual registered for appropriate reemployment services? / Yes No
Does the individual have a reasonable expectation of securing suitable* employment in the local commuting area? If no, why not? ______
______/ Yes No
Has the individual obtained suitable* employment, or a bona fide offer of such, affording a reasonable expectation of long-term duration outside the commuting area and in the area of intended relocation? / Yes No
Has the worker submitted this application timely (see page one) and before beginning the relocation? / Yes No
Relocation allowance is recommended not recommended.
Signature of TAA counselor ______Date
*Suitableemployment -- for the purposes of relocation allowance -- means suitable work as defined in the applicable state law for claimants for regular compensation or suitable work as defined in applicable state law provisions consistent with section 202(a)(3) of the Federal-State Extended Unemployment Compensation Act of 1970, whichever is applicable; it does not in any caseinclude self-employment or employment as an independent contractor. TAA-860