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FAMILY FIRST CORONAVIRUS RESPONSE ACT (FFCRA)-EXPANDED FMLA (CHILDCARE) REQUEST
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Department (not division)
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.
No other person will be providing care for my child during the period for which I am receiving Childcare FMLA.
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.
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.
Please enter the name, DOB and ages of the child(ren) you are caring for.
Childs #1 Full Name
School/Childcare Provider & Providers Contact Number for Child #1
Child #2 Full Name
School/Childcare Provider & Providers Contact Number for Child #2
Child #3 Full Name
School/Childcare Provider & Providers Contact Number for Child #3
Amount of Leave Requested-I am requesting leave for the following period of time.
I elect to use my PPL or Comp Time to supplement my partial paid FMLA during this time
I attest the above statements are true.
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