Form Regarding FMLA Leave to Care for a Family Member by WorkSession

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									    Form Regarding FMLA Leave to Care for a Family Member
I, __________________, have requested time off work to care for __________________.
I have read the definitions below and I confirm that this person qualifies as my
_______________.

I have attached a copy of the following documents confirming this relationship:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Date: ________________________________

Signature: ____________________________


Definitions:
Spouse: A husband or wife to whom you are legally married.
Parent: Your legal parent, or someone who had day-to-day responsibility for supporting
your financially and taking care of you when you were a child.
Child: Your biological child, adopted child, stepchild, foster child, or legal ward, or a
child whom you have the day-to-day responsibility to support financially and take care
of. Children are covered only until they reach the age of 18, unless they are incapable of
taking care of themselves because of a physical or mental disability.

								
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