County Of Alameda Family And Medical Leaves Certification For Military Family Leave (Qualifying Exigency)

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COUNTY OF ALAMEDA

FAMILY AND MEDICAL LEAVES

CERTIFICATION FOR MILITARY FAMILY LEAVE (Qualifying Exigency)

Pursuant to the federal Family Medical Leave Act (FMLA), the purpose of this form is to provide sufficient facts to support a request for

military family leave due to a qualifying exigency. Qualifying exigency leave allows employees time off for reasons related to their family

member who is a covered military member on active duty.

For Employee: Please complete this form in its entirety (Sections I – III). Be as specific as possible; terms such as “unknown,” or

“undetermined,” may not be sufficient to determine FMLA coverage and may result in the denial of your leave request. Submission of a

timely, completed and sufficient certification to support a request for FMLA leave due to a qualifying exigency is required to obtain the

FMLA benefit. You must return the required certification to your Agency/Department Human Resources Office within 15 days.

SECTION I

Employee’s Name: _____________________________________________ Employee’s ID Number: ___________________________________________________

Classification: _________________________________________________ Department: _____________________________________________________________

Contact Telephone Number: _____________________________________ Immediate Supervisor: ____________________________________________________

Name of covered military member on covered active duty:__________________________________________________________________________________

Relationship of covered military member to you:__________________________________________________________________________________________

Period of covered military member’s covered active duty:

From:__________________

Through:_________________

SECTION II (PARTS A, B & C)

(P t

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 covered active duty status. 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 covered active duty is attached

I have previously provided my employer with sufficient written documentation confirming the covered military member’s covered active duty status.

QUALIFYING REASON FOR LEAVE (PART A)

Describe the reason you are requesting FMLA leave due to a qualifying exigency (be specific):

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

None available

FML Certification for Military Family- Qualifying Exigency (FORM 4)

REV. 11/10

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