Upon completion of this form, submit it to Human Resources for processing. H�2�3U0��t.=s#0a�gd!�R�Ҹ ��� endstream endobj 87 0 obj <>/Subtype/Form/Type/XObject>>stream 1 1 8.68 9.3318 re 0 0 10.68 11.3318 re endstream endobj 82 0 obj <>/Subtype/Form/Type/XObject>>stream EMC 1.8 1.8 7.08 7.08 re Eligibility Notice, form WH-381 – informs the employee of his or her eligibility for FMLA leave or at least one reason why the employee is not eligible. 1.8 1.8 7.08 7.08 re H�2�3U0��t.=s#0a�gd!�R�Ҹ@��P�B����X � �b *�*0L�"ѥ&/�� $�]����H��&���X��^&M�!0 H2nQ��Fe&_�ċ�@�y`5� ɿm�����l#�(Ie�?S�q� r)� 114 0 obj <>/Filter/FlateDecode/ID[]/Index[62 112]/Info 61 0 R/Length 155/Prev 246274/Root 63 0 R/Size 174/Type/XRef/W[1 3 1]>>stream H�2�3U0��t.=s#0a�gd!�R�Ҹ ��� Employees requesting Emergency FMLA (EFMLA) pursuant to the Families First Coronavirus Response Act (FFCRA) must complete this form. f endstream endobj 89 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 63 0 obj <>/Metadata 3 0 R/Names 116 0 R/Pages 60 0 R/StructTreeRoot 10 0 R/Type/Catalog/ViewerPreferences 118 0 R>> endobj 64 0 obj <>/MediaBox[0 0 612 792]/Parent 60 0 R/Resources<>/ProcSet[/PDF/Text]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 65 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 0 rg You must provide as much advance notice as is reasonably practicable. H�2�3U0��t.=s#0a�gd!�R�Ҹ@��P�B����X � �b H�2�3U0��t.=s#0a�gd!�R�Ҹ ��� (n) Tj endstream endobj 84 0 obj <>/Subtype/Form/Type/XObject>>stream 2.4649 3.1081 Td h�bbd```b``>"7�H�nɰ ����HQ �/@jB;@�j;d&���b�l�M@��H���4vP�(9�����[ ��@H BT �+! q %PDF-1.6 %���� %%EOF 1.8 1.8 7.08 7.08 re 10/20) Page 3 . EMERGENCY FAMILY AND MEDICAL LEAVE EXPANSION ACT REQUEST – CONTINUED . /Tx BMC endstream endobj 86 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 81 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 72 0 obj <>/Subtype/Form/Type/XObject>>stream ET 212 0 obj <>stream 0.749023 g /ZaDb 7.5563 Tf 0 W endstream endobj 85 0 obj <>/Subtype/Form/Type/XObject>>stream EMC 7.2767 TL EMC EPSL Request Form Rev. EMPLOYEE REQUEST FOR EMERGENCY FAMILY AND MEDICAL LEAVE Emergency Responders are excluded from this FMLA expansion Employees requesting Emergency FMLA (EFMLA) pursuant to the Families First Coronavirus Response Act (FFCRA) must complete this form. endstream endobj 76 0 obj <>/Subtype/Form/Type/XObject>>stream H�2�3U0��t.=s#0a�gd!�R�Ҹ ��� endstream endobj 74 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 68 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 80 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj startxref 4/202 (General) Employees requesting Emergency Paid Sick Leave (EPSL) or Emergency FMLA (EFMLA) pursuant to the Families First Coronavirus Response Act (FFCRA) must complete this request form. endstream endobj 70 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 77 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 88 0 obj <>/Subtype/Form/Type/XObject>>stream 18 0 obj <> endobj endstream endobj 73 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 71 0 obj <>/Subtype/Form/Type/XObject>>stream f Retain this documentation for four years from the date of the request. endstream endobj startxref %PDF-1.7 %���� This sample form can be used to document information needed from an employee requesting emergency family and medical leave under FFCRA to substantiate eligibility for tax credits, per the IRS. endstream endobj 66 0 obj <>/Subtype/Form/Type/XObject>>stream 1 . endstream endobj 78 0 obj <>/Subtype/Form/Type/XObject>>stream ,�L�������gd����D�! endstream endobj 69 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 0 rg H�E��>�-�gv6�ӊv6€`�h���������Q��krNP*M�4���5����hl_��`^� ���z;�Ye�3F$�%w��6c. EMERGENCY FAMILY AND MEDICAL LEAVE EXPANSION ACT (EFMLEA) REQUEST FOR LEAVE Please complete and submit this form to Human Resources or your Supervisor. /Tx BMC 62 0 obj <> endobj endstream endobj 90 0 obj <>/Subtype/Form/Type/XObject>>stream H�2�3U0��t.=s#0a�gd!�R�Ҹ@��P�B����X � �b Employees requesting either Emergency Paid Sick Leave or Emergency Family and Medical Leave must complete this form, collect 0 0 0 rg 135 0 obj <>/Filter/FlateDecode/ID[<0CB787F418649837354E79B7607FE487><1FDDF076648DF24983E6BF5781CB23DC>]/Index[18 195]/Info 17 0 R/Length 264/Prev 380543/Root 19 0 R/Size 213/Type/XRef/W[1 3 1]>>stream Belgrade School District - Employee Request Form - Emergency FMLA 1910F2. 1.8 1.8 7.08 7.08 re Q 0 0 0 rg EMPLOYEE REQUEST FOR EMERGENCY PAID SICK LEAVE ACT/EMERGENCY FAMILY AND MEDICAL LEAVE EXPANSION ACT . endstream endobj 93 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 173 0 obj <>stream 0 H�2�3U0��t.=s#0a�gd!�R�Ҹ ��� f Employees may be entitled to Emergency FMLA (EFMLA) in accordance with the Families First Coronavirus Response Act (FFCRA) if the employee satisfies eligibility standards. h�b``0b``.c ˖1�6 fa�hs:�I�30�a`x��� d+2X2xaм`�)��`ʰ H�1��I0�`)`~�2�y-�L�o��E#�E�N��m����Ռ̫d�4�W�ql�Tn��L���r%T�_簟L���P���y� D9s�V��W!�� Rights and Responsibilities Notice, form WH-381 (combined with the Eligibility Notice) – informs the employee of the specific expectations and obligations associated with the FMLA leave request and the consequences of failure to meet those obligations. f endstream endobj 79 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 91 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Please note: All existing certification requirements under the FMLA remain in effect if you are taking leave for an existing claim /Tx BMC endstream endobj 83 0 obj <>/Subtype/Form/Type/XObject>>stream You must provide as much advance notice as is EMC CDCR (Rev. EMC MRA Edge September/October 2020 1.8 1.8 7.08 7.08 re EMC /Tx BMC Download/Print Copy . n endstream endobj 75 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 67 0 obj <>/Subtype/Form/Type/XObject>>stream H�2�3U0��t.=s#0a�gd!�R�Ҹ@��P�B����X � �b %%EOF 0 0 0 rg f endstream endobj 92 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 Td /Tx BMC f /Tx BMC EMPLOYEE REQUEST FOR EMERGENCY PAID SICK LEAVE OR EMERGENCY FAMILY AND MEDICAL LEAVE FOR COVID-19 (CORONAVIRUS) RELATED REASON AND SELF CERTIFICATION . h�b``(f`0ef```m�f@�@������� �4C1C� ��l��-��l�p`o`��X�����A��{3P��D�t�� ��0�a��`�`x@��}[��oǁv��70�`�a��P �"w@U�q�|P����x��~�@�΁�8 5Ä��#�� r O��1�fm�w�䁊��y��4�02��o;��n��L$�U. H�2�3U0��t.=s#0a�gd!�R�Ҹ@��P�B����X � �b h�bbd```b``���n �i�d������ �L2�D��^`�"i"LH"H�@L��Ť �W��"�B�a�a@RÄ��9W�LC2�]Pv(�]۱���ȺPB��-PCqآ� A�e�\&��H�8��=Lz�E\A$3+Xl ش^ ɘ!6GLր�HXɁɩ ��� 6�!

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