Certification By Employee Of Qualifying Exigency For Military Family Leave - Fmla


Employee’s name:
Name of covered military member on active duty or call to active duty status:
Relationship of covered military member to employee:
Dates of covered military member’s active duty service:
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 documentation confirming the covered military member’s
active duty or call to active duty status in support of a contingency operation.
Description of qualifying exigency (On the back of this form is the description of a “qualifying exigency” under FMLA.
Does the need for leave qualify under any of the categories described? If so, please check the applicable category.
(1) _______ (2) ________ (3) ________ (4) ________ (5) ________ (6) ________ (7) ________ (8) ________
Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason your are
requesting leave):
Please attach 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
counselor or school official, or a copy of a bill for services for the handling of legal or financial affairs. Available written
documentation is attached. ______ Yes ______ None Available
Approximate date exigency commenced or will commence: _________________________________________________________
Probable duration of exigency: _________________________________________________________________________________
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: _____________________________________________
Will you need to be absent from work periodically to address this qualifying exigency? _____ Yes _____ No
Estimate the frequency and duration of each period of absence due to the qualifying exigency (e.g. 3 x per month lasting 4 hours):
Frequency: _________ times per _________ week(s) _________ month(s).
Duration: _____________ hour(s) or _________ day(s) per event.
Leave to Meet with a Third Party. Please complete this section if leave is requested to meet with a third party (such as to arrange for
chilcare, to attend counseling, to attend meetings with school or chilcare 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). This information may be
used by your employer to verify that the information contained on this form is accurate.
Name of Individual or Entity with whom you are meeting: ________________________________Title ________________________
Organization: _____________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Telephone _____________________________ Fax: ________________________________
Email: _______________________________________________________________
Briefly describe the purpose of the meeting: ______________________________________________________________________
I certify that the information I provided above is true and correct.
Signature of Employee: _____________________________________________________
Date: _______________________


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