(Family and Medical Leave Act of 1993)
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The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking military family leave due to a qualifying exigency to submit a timely, complete, and sufficient certification to support the request for leave. The employee should complete this form fully and completely. Several questions in this section seek a response as to the frequency or duration of the qualifying exigency. Be as specific as you can; terms such as “unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Your response is required to obtain a benefit. While you are not required to provide this information, failure to do so may result in a denial of your request for FMLA leave. You have 15 calendar days to return this form to your supervisor.
Your Name: _________________________________________________________________________________
First Middle Last
Name of covered military member on active duty or call to active duty status in support of a contingency operation:
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First Middle Last
Relationship of covered military member to you: ____________________________________________________
Period of covered military member’s active duty:____________________________________________________
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a covered military member’s active duty or call to active duty status in support of a contingency operation. Please check one of the following:
A copy of the covered military member’s active duty orders is attached.
Other documentation from the military certifying that the covered military member is on active duty (or has been notified of an impending call to active duty) in support of a contingency operation is attached.
I have previously provided my employer with sufficient written documentation confirming the covered military member’s active duty or call to active duty status in support of a contingency operation.
PART A: QUALIFYING REASON FOR LEAVE:
1. Describe the reason you are requesting FLMA leave due to a qualifying exigency (including the specific reason you are requesting leave):
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2. A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes any available written documentation which supports the need for leave; such documentation may include a copy of a meeting announcement for informational briefings sponsored by the military, a document confirming an appointment with a counselor or school official, or a copy of a bill for services for the handling of legal or financial affairs. Available written documentation supporting this request for leave is attached.
____Yes ____No______None Available
PART B: AMOUNT OF LEAVE NEEDED:
1. Approximate date exigency commenced_________________________________________________________
Probable duration of exigency:________________________________________________________________
2. Will you need to be absent from work for a single continuous period of time due to the qualifying exigency?
____Yes ____No.
If so, estimate the beginning and ending dates for the period of absence:
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3. Will you need to be absent from work periodically to address this qualifying exigency? _____Yes ____No.
Estimate schedule of leave, including the dates of any scheduled meetings or appointments:
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Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time (i.e., 1 deployment-related meeting every month lasting 4 hours):
Frequency: _______times per______week(s)_______month(s)
Duration: ______hours ______day(s) per event.
PART C:
If leave is requested to meet with a third party (such as to arrange for childcare, to attend counseling, to attend meetings with school or childcare providers, to make financial or legal arrangements, to act as the covered military member’s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and sufficient certification includes the name, address, and appropriate contact information of the individual or entity with whom you are meeting (i.e., either the telephone or fax number or email address of the individual or entity). This information may be used by the County Government to verify that the information contained on this form is accurate.
Name of Individual:______________________________ Title:______________________________________
Organization:_________________________________________________________________________________
Address:_____________________________________________________________________________________
Telephone: (_____) _____________________________ Fax: (_____)________________________________
Email:_______________________________________________________________________________________
Describe nature of meeting:______________________________________________________________________
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PART D:
I certify that the information I provided above is true and correct.
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Signature of Employee Date