Family And Medical Leave - Employee Request - State Of Wisconsin Office Of State Employment Relations Page 2

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SECTION 2: For completion by the EMPLOYEE who is taking leave to care for a domestic
partner or a domestic partner's parent ONLY.
Effective June 30, 2009, employees are allowed to take up to two weeks of Wisconsin FMLA leave to care for a
domestic partner or a domestic partner's parent who is suffering from a serious health condition. Employees can
exercise this right under the Wisconsin FMLA as either a registered or unregistered domestic partner.
In order to be eligible to take Wisconsin FMLA leave under these provisions, you must satisfy one of the
following requirements. Please check the box that applies to your domestic partnership:
I have a registered domestic partnership with the Register of Deeds in a county in the state of Wisconsin.
I am in an unregistered domestic partnership. I am in a relationship with another individual and we satisfy
all of the following requirements:
We are both at least 18 years old and otherwise competent to enter into a contract;
Neither of us is married to, or in a domestic partnership with, another individual;
We share a common residence;
We are not related by blood in any way that would prohibit marriage under Wisconsin law;
We consider ourselves to be members of each other's immediate family; and
We agree to be responsible for each other's basic living expenses.
Certification of Domestic Partnership for Wisconsin FMLA Purposes Only:
I certify that _________________________________________________________ is my domestic partner.
(Name of Domestic Partner)
Employee Signature: _________________________________________________
Date: ___________________
For Employer Use Only
Leave Request is:
Approved (Circle: FMLA / WFMLA / Both )
Not Approved (explain below):
Authorizing Signature: ________________________________________________
Date: ___________________
If leave request is not approved, please explain reason for denial of request:
OSER-DCLR-201 (revised 3/5/13)
s.103.10, Wis. Stats.

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