Form Wh-384 - Certification Of Qualifying Exigency For Military Family Leave (Family And Medical Leave Act) Page 3
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3PART C:
If leave is requested to meet with a third party (such as to arrange for childcare or parental care, to attend counseling, to
attend meetings with school, childcare or parental care providers, to make financial or legal arrangements, to act as the
military member’s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing
military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and
sufficient certification includes the name, address, and appropriate contact information of the individual or entity with
whom you are meeting (i.e. , either the telephone or fax number or email address of the individual or entity). This
information may be used by your employer to verify that the information contained on this form is accurate.
Name of Individual: ______________________________ Title: ______________________________________________
Organization: ______________________________________________________________________________________
Address: __________________________________________________________________________________________
Telephone: (________) ___________________________ Fax: (_______) ______________________________________
Email: ____________________________________________________________________________________________
Describe nature of meeting: ___________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PART D:
I certify that the information I provided above is true and correct.
Signature of Employee ___________________________________________ Date _______________________________
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29 U.S.C. 2616; 29 CFR 825.500.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. T he Department
of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including
suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200
Constitution AV, NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THE WAGE AND HOUR DIVISION;
RETURN IT TO THE EMPLOYER.
Page 3
WH-384 Revised February 2013
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