Form Pfl-1 And Pfl-2 - Paid Family Leave Forms Page 9
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10Request For Paid Family Leave
Bonding Certification (Form PFL-2)
INSTRUCTIONS INCLUDED WITH FORM
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (first name, middle initial, last name)
Employee’s date of birth (MM/DD/YYYY)
/
/
Other last names, if any, under which employee has worked
Employee’s Social Security Number or TIN
-
-
Employee’s mailing address
Mailing address
City, State
Zip code
Country (if not U.S.A.)
BONDING CERTIFICATION (to be completed by the employee)
1. Child’s date of birth (MM/DD/YYYY)
/
/
Male
Female
Not designated/Other
2. Child’s gender
Yes
No
3. Does child live with the employee requesting PFL?
Child is employee’s:
Biological child
Stepchild
Foster child
Adopted child
Legal ward
Spouse/Domestic partner’s child
4.
5. Select one of the following and attach the document as required as evidence of the relationship.
Parent of newborn child:
Birth mother:
Health care provider certification of pregnancy (include expected due date AND mother’s name); OR
Health care provider certification of birth (include date of birth of child AND mother’s name); OR
Child’s birth certificate
Other parent:
Copy of birth certificate naming second parent; OR
Voluntary acknowledgment of paternity; OR
Court order of filiation; OR
Birth mother documents (see above) PLUS one of the following:
Marriage certificate; OR
Certificate of civil union; OR
Evidence of domestic partnership
OR; Other documentation of parental relationship
Foster parent:
Letter of foster care placement or anticipated placement issued by county or city department of Social Services or authorized voluntary foster care agency
Adoptive parent:
Court document finalizing adoption
Documentation in furtherance of adoption
/
/
6. Date of foster care or adoption placement, if applicable (MM/DD/YYYY)
Form PFL-2 continued on next page
PFL-2 (10-17) Bonding Certification
If you need assistance, please call (844) 337-6303
Page 1 of 2
PFL-2 10-17
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