Trade Adjustment Assistance Program Reemployment Trade Adjustment Assistance (RTAA) New Employment Verification Form Section 1 Employee Information Name State ID Address (No.Street, City, Number State, Zip Code) Section 2 New Employer Information State Tax Employer Name ID # Address (No.Street, City, State, Zip Code) Phone Number Fax Number To be completed by the new employer RTAA is a wage supplement program for older workers who find new employment at lower wages. If all eligibility criteria are met, the worker can receive… 50% of the difference between his/her from the trade-certified job and the new job, paid up to a maximum of $10,000 or for two years, whichever occurs first. New employment may not pay more than $50,000 per year and may be: full time (at least 30 hours per week; can be two or more jobs); or part time (at least 20 hours per week; must be enrolled in full-time TAA-approved training) In order to determine the eligibility of the worker named above, please complete and return this form to the worker for inclusion in their application package. Salary Hourly First Day Type of Job Title Commission Worked Employment Contractual Pay Rate Hours Worked per Employment (First Per Full Time Part Time Week Status Full Week Worked) (First full week) Section 3 Acknowledgment By signing below, I certify that the information provided above is true and correct to the best of my knowledge. Employer’s Representative Name Title Representative’s Representative’s Phone Number Fax Number Representative’s Date Signature
Trade Adjustment Assistance Program Reemployment Trade Adjustment Assistance (RTAA) New Employment Verification Form Section 1 Employee Information Name State ID Address (No.Street, City, State, Zip Code) Number Section 2 New Employer Information Employer Name State Tax ID # Address (No.Street, City, State, Zip Code) Phone Number Fax Number To be completed by the new employer RTAA is a wage supplement program for older workers who find new employment at lower wages. If all eligibility criteria are met, the worker can receive… 50% of the difference between his/her from the trade-certified job and the new job, paid up to a maximum of $10,000 or for two years, whichever occurs first. New employment may not pay more than $50,000 per year and may be: full time (at least 30 hours per week; can be two or more jobs); or part time (at least 20 hours per week; must be enrolled in full-time TAA-approved training) In order to determine the eligibility of the worker named above, please complete and return this form to the worker for inclusion in their application package. First Day Worked Job Title Type of Employment Salary Hourly Commission Contractual Pay Rate (First Full Week Worked) Per Hours Worked per Week (First full week) Employment Status Full Time Part Time Section 3 Acknowledgment By signing below, I certify that the information provided above is true and correct to the best of my knowledge. Employer’s Representative Name Title Representative’s Phone Number Representative’s Fax Number Representative’s Signature Date
New_RTAA_Employment_Verification_Form.docx