TAA-860 (Rev.

7/2005)
Connecticut Department of Labor
Request for Relocation Allowances
Trade Act of 1974, as amended
Worker’s Name (Last, First, Middle) Social Security No. Job Center Date

Address Petition No. Company Paying

State

Is this worker’s first request for

Date of total separation from adversely affected employment
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 90 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.
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 Yes
any other source? If yes, indicate amount of reimbursement and provide full details on the reverse side. No

Worker Request for Travel Allowance

90 percent of the total costs of the more cost effective mode of transportation reasonably available and the cost allowable for lodging and
meals while in travel status for the individual and family, if any, from the individual's place of residence to the area of relocation. If, for
good cause, a member or members of an individual's family must travel separately to the individual's new residence, 90 percent of the
total costs of such separate travel shall be included in calculating the total amount the individual is 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 the
individual be paid a travel allowance for the individual or a member of the individual's 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 Travel dates Auto Commercial carrier
worker and family members, if any 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
Name Age Relationship family members
 Worker Request for Moving Allowance - Complete either section A, B or C and complete section D
90 percent of the expenses of moving household goods and personal effects of the individual 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 an individual and family, if any, from the individual's old residence to
the individual's new residence in the area of relocation, including reasonable and necessary accessorial charges, by the most economical
commercial carrier the individual reasonably can be expected to use. Before undertaking such move, the individual must submit to the
state agency an estimate from a commercial carrier as to the cost thereof. 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 a bid from a licensed insurer is
obtained by the individual and approved by the state agency before departure. If a state agency finds it is more economical to pay a
carrier an extra charge to assume the responsibility of a common carrier for such goods and effects, 90 percent of such extra charge, but
not exceeding $ 50, shall be paid in lieu of the cost of insurance.
Other accessorial costs,
Moving cost $ Insurance cost $ 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 rental fee for each
the private vehicle at the prevailing mileage rate authorized under the day reasonably required
federal travel regulations (see 41 CFR Part 101-7) for the usually $ to complete the move $
traveled route from the individual's old residence to the individual's new
residence in the area of relocation, unless already covered by the
allowance for travel, AND
allowance The necessary fuel for
if the trailer is rented, the rental fee for each day reasonably required to $ such rental truck paid by $
complete the move the individual.
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 the individual's place of residence in the old area and will be so used in the new area
The commercial Charges for Ferry charges, bridge, road, and tunnel tolls, The cost of insuring the house trailer or
carrier's charges for unblocking and taxes, fees fixed by a state or local authority mobile home, and the personal effects of the
moving the house re-blocking for permits to transport the unit in or through its individual and family, against loss or damage
trailer or mobile home jurisdiction, and retention of necessary in transit [in accordance with the provisions
flagmen (provide breakdown on reverse side) 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

A lump sum payment, equal to three times the individual's Average weekly Multiplied by
average weekly wage, not to exceed $1,250. wage: $ 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
Yes No
commuting area? If no, why not? _____________________________________________________
________________________________________________________________________________
Has the individual obtained suitable* employment, or a bona fide offer of such, affording a reasonable Yes No
expectation of long-term duration outside the commuting area and in the area of intended relocation?
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
*Suitable employment -- 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 case include self-employment or employment as an independent contractor. TAA-860