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FAMILY FIRST CORONAVIRUS RESPONSE ACT (FFCRA)-EXPANDED FMLA (CHILDCARE) REQUEST

  1. I am unable to work, including by means of telework, due to a bona fide need to care for my child who is under 18 years of age whose school or child care provider is closed or unavailable for reasons related to COVID19. *

  2. No other person will be providing care for my child during the period for which I am receiving Childcare FMLA. *

  3. I understand that I must provide a statement of Special Circumstances for any child 14 years of age or older requiring me to provide care during the day.

  4. I understand that I am entitled to take up to a total of 12 work weeks of leave during a 12-month period under the Expanded FMLA (Childcare) provision and that this time will also count towards my leave entitlement under the FMLA. *

  5. Please enter the name, DOB and ages of the child(ren) you are caring for.

  6. Amount of Leave Requested-I am requesting leave for the following period of time.

  7. I elect to use my PPL or Comp Time to supplement my partial paid FMLA during this time*

  8. I attest the above statements are true.*

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