Fsd 18 Special Family Separation Assistance Application Form Page 2

DECLARATION OF EMPLOYEE



I hereby certify that the information provided in this declaration is correct and that there is no separation due to

relationship breakdown.



I acknowledge that it is my responsibility to inform my department of any change or event that may change the

information provided above.



I acknowledge that benefits claimed under false pretences will be recovered and I will be subject to disciplinary action.

Employee’s signature: _____________________________________

Date: ____________________

□

Request:

Approved

Denied

Department approval: _____________________________________

Date: ____________________

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Parent category: Business