Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Families First Coronavirus Response Act - Related Leave Request

  1. Expanded FMLA Leave
    I need to care for a son or daughter under the age of 18 whose school or daycare is closed (or child care provider is unavailable) because a Federal, State or local authority has declared a public health emergency related to COVID-19. No other suitable person will be caring for the child during the period for which I am requesting leave.
  2. Please provide additional information to support the reason for your request including additional clarification or documentation that you believe is relevant to your request. Failure to provide requested information may result in your request being delayed or denied.
  3. Signature/Confirmation
    By submitting this form, I certify that the information I have provided is true and accurate.
  4. Leave This Blank:

  5. This field is not part of the form submission.