ETA-9103-4 PLANNING FORM 4 Trade Health Insurance Coverage Assistan

PLANNING FORM* 4 – Trade Health Insurance Coverage Assistance OMB Approval No. 1205-0439

All quarterly entries are CUMULATIVE over all previous quarters Expiration Date: 01/31/07

Performance Factor

program year quarter

Admin

Program

Qtr 1

Qtr 2

Qtr 3

Qtr 4

Qtr 5

Qtr 6

Qtr 7

Qtr 8

Qtr 9

Qtr 10

Qtr 11

Qtr 12

Implementation Schedule

Total Planned Participants

Receiving Supportive Services

Receiving Health Coverage Payments

Total Expenditures

Supportive Services

Health Coverage Payments

Program Management and Oversight

Admin., Excluding Premium Payment Processing*

Premium Payment Processing

Other *

Indirect

Other*

*This form must be accompanied by an appropriate budget narrative which lists, for each *ed line item, components of the costs, e.g. staff salaries, fringe benefits, equipment, travel, facilities, and the estimated cost amounts for each.

ETA 9103

The reporting requirements are approved by OMB according to the Paperwork Reduction Act of 1995 under OMB approval No. 1205-0439. NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondent’s obligation to reply to these reporting requirements are mandatory (PL: 107-210). Public reporting burden for this collection of information is estimated at 15 minutes. Send comments regarding the burden estimate or any other aspect of this collection, including suggestions for reducing this burden to the U.S. Department of Labor, Office of National Response, Room N-5422, Washington D.C. 20210. (Paperwork Reduction Project 1205-0439).