Exelon Parental Leave Request Form/fmla Certification Of Birth, Or Placement Of Child For Adoption Or Foster Care
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2Exelon FMLA Form C-3
Parental Leave Request Form/FMLA
Certification of Birth, or Placement of Child
for Adoption or Foster Care
TO BE COMPLETED BY EMPLOYEE
Name: ____________________________________________
Date: ____________
Exelon Company/Location:
________________________
Emp. #:___________
Dept. Name and Number (if known) _____________________
Supervisor: ___________________________
Job Title:___________________________________________
Status: __ Full-Time __ Part-Time
Date of Hire:________________________________________
If break in service, prior Date of Hire:______
1.
Please indicate below the reason for the requested Parental and/or FMLA leave:
____
Birth of a child (check only if the employee requesting leave is pregnant, and then complete form C-6 at
time disability begins and/or following the birth of child)
____
Care and bonding with a newborn child
____
Adoption of a child and/or care and bonding of a newly adopted child
____
Placement of child with employee for foster care/care and/or bonding of newly placed foster child
2.
I anticipate that my leave will start on __________________ and end on ___________________.
3a.
Is your spouse employed by an Exelon company? __ Yes ___No ; If Yes, which one:__________________
3b.
If you answered “Yes” to 3a., did your spouse take or is your spouse planning to take any leave for the birth, adoption or
placement of a child with you for foster care? __ Yes ___No
3c.
If you answered “Yes” to 3b., when was the leave taken or for how long has it been requested? __/__/__ to __/__/__
4.
Are you requesting leave because your domestic partner is giving birth to a child or adopting a child? ___Yes ___No.
(Please see Exelon’s Parental Leave Time Policy (HR-AC-500) for information on paid parental lave for domestic partners.)
USE OF UNPAID FMLA LEAVE AND PARENTAL LEAVE
If you are eligible for FMLA leave, any period during which you are receiving paid parental leave will run concurrently with (at the
same time as) any available unpaid FMLA leave. This means that you are using any unused FMLA leave while out on paid parental
leave. For further information on parental leave, see Exelon’s Parental Leave Time Policy (HR-AC-500).
If you are not eligible for, do not apply for, or have exhausted your paid parental leave, you still may be eligible for FMLA leave. If
your FMLA leave is approved, absent any applicable collective bargaining agreement that provides otherwise, you will be required to
use any other paid benefits available to you, such as accrued, applicable vacation, sick and floating holidays (up to the reserves) during
your FMLA leave. This means that you will receive paid leave and the leave also will be considered FMLA protected leave and will
count against your FMLA leave entitlement. Any remaining FMLA leave after exhaustion of paid leave will be unpaid FMLA leave.
If you are not eligible for FMLA leave, you still may be eligible for paid parental leave. Exelon provides two (2) weeks of paid
parental leave for eligible employees, subject to certain conditions. For further information on parental leave, see Exelon’s Parental
Leave Time Policy (HR-AC-500).
____________________________________
_________________________________
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