Dartmouth College Application For Family/medical Leave Form (Page 2 of 2) in pdf

Dartmouth College Application For Family/medical Leave Form Page 2

PAYMENT ELECTIONS

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I will continue to receive regular paychecks less unpaid Family Medical Leave hours. My benefits will continue to be

deducted from my paycheck.

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I wish to make payment at this time.

(Please contact the Benefits Office at (603) 646-3588 for payment amount.)

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Please bill me on a monthly basis at the following address: ____________________________________________

____________________________________________

I agree to pay in full for the amounts billed monthly. I understand that if I do not make full payment each month, within 25

days of the due date, that my benefits will be cancelled. I understand I will be responsible for the outstanding balance, a

finance charge of 1.5% per month, and any collection or attorney costs incurred in collecting the balance due. Upon my

return, if there is any outstanding balance, I authorize the College to collect overdue amounts including finance charges,

through payroll deduction.

Note: An employee requesting leave for the employee’s serious health condition or the serious health condition

of the employee’s spouse, child or parent must submit a verifying Medical Certification from the physician within

15 days of the application for leave.

I understand that failure to return to work at the end of my leave period may be treated as a resignation unless an

extension has been agreed upon and approved in writing by Dartmouth College.

Signature: __________________________________________Date:_______________________

(Required)

Approved by:

Human Resources Representative:

___________________________________________________ Date: ______________________

Return to:

Telephone: (603)646-3588

Fax: (603)646-1108

Dartmouth College Application For Family/medical Leave Form Page 2