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Family and Medical Leave Act (FMLA) Request Form

  1. Application Status

  2. An FMLA leave of absence is a leave without pay. Paid leave (using accrued Personal Time Off/PTO hours) shall be substituted for the unpaid leave in accordance with the Family Medical Leave Act policy.

  3. I understand that I am required to complete a FMLA Leave Certification of Health Care Provider form (found on the City's web site) and submit the form to Human Resources before my leave commences. I understand that if my leave is approved, my time away from work will be charged againas my 12-week leave maximum under FMLA. Upon approval of this requested leave, I am required to utilize all paid time off available to me prior to going into an unpaid leave status. In the event that I go into an unpaid status while on leave, I understand that I must contact the City Clerk/Payroll Administrator to make arrangements to pay my portion of health insurance premiums.

  4. I understand that one of the below Certification of Health Care Provider documents must be returned to Human Resources within 15 days of my request. If I am not able to return the form within the allowed timeframe, I will contact Human Resources for assistance. If this information is not received in the required timeframe, I understand that my leave may be considered unauthorized.

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