Form Pfl-1 And Pfl-2 - Paid Family Leave Forms Page 8
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10Bonding Certification (Form PFL-2) Instructions
If the employee is requesting PFL to bond with a newborn, an adopted child or a foster child, the employee must
submit the Bonding Certification (Form PFL-2) with the Request For Paid Family Leave (Form PFL-1).
BONDING CERTIFICATION (to be completed by the employee)
The employee requesting PFL must complete all applicable requested information.
Send completed forms and supporting documentation to insurance carrier.
If this form is being submitted in advance (pre-submitting) and some information is unknown,
the insurance carrier will contact the employee and explain how to provide the required additional information.
Questions 1 & 2:
If the form is submitted to the PFL insurance carrier prior to the birth of a child, this is considered pre-
submitting. The employee is then required to provide the required documentation of the child’s birth to the PFL insurance
carrier. The PFL carrier will tell the employee how to provide the required additional documentation.
There may be instances where PFL can be taken before the adoption or foster care is finalized. For example, the employee
may be required to appear in court or travel to another country as part of the adoption or foster care process. The employee
should include documentation to show that the PFL is necessary to further the adoption or foster care.
Question 5:
See chart below for documentation details. Unless specified, do not send the original documents.
Bonding Form/Certification
Description
Health care provider
An original letter obtained from the birth mother’s health care provider that certifies
certification of pregnancy
pregnancy. It should include the mother’s name and the expected due date.
Health care provider
An original letter obtained from the birth mother’s health care provider that includes the
certification of birth
mother’s name and child’s date of birth.
Birth Certificate
A copy of the certificate issued by the city or county office in which the child is born.
A copy of the form that establishes legal fatherhood when the parents are unmarried.
Voluntary Acknowledgment of
Completed by both mother and father.
Paternity (Form LDSS-4418)
For more information, see
childsupport.ny.gov/dcse/aop_howto.html
A copy of the order from the family court that names the father of a child. Establishes legal
Court Order of Filiation
fatherhood when the parents are unmarried. Completed by both mother and father.
For more information, visit
childsupport.ny.gov/dcse/aop_howto.html
A copy of the official statement issued by the town or city clerk from which the marriage
Marriage Certificate
certificate was issued.
Civil union/domestic partner’s
A copy of the certificate of civil union or domestic partnership.
documentation
A copy of the letter of foster care placement issued by the county or city department of
Foster care placement letter
social services or authorized voluntary foster care agency.
A copy of the court document finalizing adoption or documentation in furtherance or court
Court documents of adoption
order finalizing adoption.
Other documentation
Other documentation of parental relationship may be accepted if none of the others listed apply.
Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 USC 552a).
The Workers’ Compensation Board’s (Board’s) authority to request that employees provide personal information, including their social security number or tax
identification number, is derived from the Board’s administrative authority under Workers’ Compensation Law section 142. This information is collected to assist
the Board in investigating and administering claims in the most expedient manner possible and to help it maintain accurate records. Providing your social security
number or tax identification number to the Board is voluntary. The Board will protect the confidentiality of all personal information in its possession, disclosing it only in
furtherance of its official duties and in accordance with applicable state and federal law.
Form PFL-2 Instructions
If you need assistance, please call (844) 337-6303
DO NOT SCAN
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