Form Pfl-1 And Pfl-2 - Paid Family Leave Forms Page 6
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10FORM PFL-1 - CONTINUED FROM PRIOR PAGE
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (first name, middle initial, last name)
Employee’s date of birth (MM/DD/YYYY)
/
/
PART B - EMPLOYER INFORMATION (to be completed by the employer)
1. Business’s full legal name and mailing address
Business name
Mailing address
City, State
Zip code
Country (if not U.S.A.)
-
2. Employer’s FEIN
3. Employer’s Standard Industrial Classification (SIC) Code
4. Employer’s contact name for questions related to PFL
(
)
-
5. Employer’s contact telephone number
6. Employer’s contact email address
/
/
7. Employee’s date of hire (MM/DD/YYYY)
-
8. Employee’s occupation Codes are available at:
9. Enter the last 8 weeks of gross wages for the employee and calculate the average gross weekly wage
Week no. Week ending date (MM/DD/YYYY)
Number of days worked
Gross amount paid
1
2
3
4
5
6
7
8
Calculated average gross weekly wage:
If employee received or will receive full wages while on PFL, will employer be requesting reimbursement?
Yes
No
10.
Form PFL-1 continued on next page
PFL-1 (10-17)
If you need assistance, please call (844) 337-6303
Page 3 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form De 1378a - Application For Unemployment Insurance, State Disability Insurance, And Paid Family Leave Elective Coverage - 2016
Legal
Form Rr 1 - Schedule 2 - Class 1 And Class 2 - Right-of-way, Terminal And Yard Lands And All Buildings, Structures And Other Improvements Thereon, Not Included Under Section 1, Class 1 And Class 4.
Financial
Schedules M-1 And M-2 (form 1120-f) - Reconciliation Of Income (loss) And Analysis Of Unappropriated Retained Earnings Per Books - 2017
Financial
Schedules M-1 And M-2 (form 1120-f) - Reconciliation Of Income (loss) And Analysis Of Unappropriated Retained Earnings Per Books - 2015
Financial
Related Categories
Parent category: Business