Paid Family Leave Claim Form - Inyo County
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1COUNTY OF INYO
EMPLOYEE APPLICATION FOR
PAID FAMILY LEAVE BENEFITS
Employee’s Name________________________________________ Home/Cell Phone #____________________
Mailing Address_______________________________________________________________________________
Dates of Leave Requested:
From______________________through_______________________________
Name and Relationship of Family Member you will provide care for: _________________________________
If family member is your son or daughter, date of birth_________________or date of adoption or foster care
placement (attach supporting documentation) ______________.
Describe care you will provide to your family member_______________________________________________
_____________________________________________________________________________________________
I declare, under penalty of perjury, that the foregoing statements are true, complete and correct to the best of
my knowledge. I agree that a photocopy of this release shall be as valid as the original.
_____________________________________
______________________________________
Employee’s Signature
Date
Employee’s Name__________________________
========================================================================
TREATING PHYSICIAN’S CERTIFICATION
RE:___________________________________
Date illness/condition commenced_____________________
Patient’s Name
Dates of family care needed:
From____________through______________ (can be an estimate; these fields
must be completed).
I certify that the serious health condition of my patient named above makes care by a family member
necessary during the dates listed above.
________________________________________
___________________________________________
Physician’s Signature
Date
Physician’s Name (Please Print)__________________________________________________________________
Type of Practice/Medical Speciality_______________________________________________________________
Telephone (______)________________________
Fax_(____)_________________________________
RETURN TO:
INYO COUNTY PERSONNEL DEPARTMENT
P.O. Box 249
Independence, CA 93526
Phone:
(760) 878-0377
FAX:
(760) 878-0465
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