Fillable FMLA Certification Family Relationship Form 3-9-16 (City University of New York)

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FMLA Certification Family Relationship Form 3-9-16 (City University of New York)

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The FMLA Certification Family Relationship Form 3-9-16 (City University of New York) form is 1 page long and contains:

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In order to approve your request for FMLA leave, CUNY is requesting information and documentation of your relationship to the individual for
whom you will be caring or for whom you are otherwise taking leave.
Under the FMLA, family members include:
- Parents (biological, adoptive, step or foster father or mother, or any other individual who stood in loco parentis to the employee when the
employee was a son or daughter)
- Spouse
- Child (biological, adoptive, step or foster children, legal wards, or a child of a person standing in loco parentis of the employee). Note: Child
must be either under age 18, or age 18 or older and "incapable of self-care because of a mental or physical disability" at the time that FMLA
leave is to commence.
Family members do not include in-laws, grandparents, siblings and other extended family members.
For purposes of military caregiver leave under FMLA, next of kin of a covered service member means the nearest blood relative other than the
covered service member's spouse, parent, son or daughter in the following order of priority:
- blood relatives who have been granted legal custody of the covered service member by court decree or statutory provisions
- brothers and sisters
- grandparents
- aunts and uncles
- first cousins
UNLESS the covered service member has specifically designated in writing another blood relative (the employee) as his or her nearest blood
relative for purposes of military caregiver leave under the FMLA.
FAMILY AND MEDICAL LEAVE ACT (FMLA) - CERTIFICATION OF FAMILY RELATIONSHIP
Name
Date
OHRM - FMLA FAMILY RELATIONSHIP CERTIFICATION FORM - 2015
RECEIVED BY (This form must be signed by the Director of Human Resources or Designee)
Contract Title
Empl. ID
Name
Employee Information:
Date
EMPLOYEE CERTIFICATION
Reason for requesting leave (Check appropriate box)
Family member is on or has been called to active duty in the military
To care for my family member with serious health condition
To care for a seriously injured or ill servicemember or veteran related to employee
I certify that the family member for whom I need to provide care for a serious health condition under the FMLA is a covered family member as
defined.
Family Member's Name
Relationship to Employee
CUNY RESERVES THE RIGHT TO REQUEST SUPPORTING DOCUMENTS SUCH AS BIRTH CERTIFICATES, MARRIAGE CERTIFICATES
AND RELEVANT COURT DOCUMENTS.
FMLA FORM 5
Signature
Signature
College
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FMLA Certification Family Relationship Form 3-9-16 (City University of New York)

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Completed 18 December 2020

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