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Certification of Qualifying Exigency U.S. Department of Labor
For Military Family Leave Wage and Hour Division
(Family and Medical Leave Act)
OMB Control Number: 1235-0003
SECTION I:For Completion by the EMPLOYER
INSTRUCTIONS to the EMPLOYER:The Family and Medical Leave Act (FMLA) provides that an employer may
require an employee seekingFMLA leave due to a qualifyingexigencyto submit a certification. Please complete Section I
before giving this form to your employee. Your response is voluntary, and while you are notrequired to use this form, you
may not ask the employee to provide more information than allowed under the FMLA regulations, 29 CFR 825.309.
oyer name: ____________________________________________________________________________________
Contact Information: _________________________________________________________________________________
SECTION II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE:Please complete Section II fully and completely. The FMLA permits an
employer to require that you submit a timely,complete, and sufficient certification to support a request for FMLAleave due
to aqualifying exigency. Several questions in this section seek a response as to the frequency or duration of the qualifying
exigency. Be as specific as you can; terms such as “unknown,” or “indeterminate” may not be sufficient to determine
FMLA coverage. Your response is required to obtain a benefit. 29 CFR 825.310. While you are not required to provide
this information, failure to do so may result in a denial of your request for FMLA leave. Your employer must give you at
least 15 calendar days to return this form to your employer.
Name of military member oncovered active duty or call to covered active duty status:
ationship of military member to you: ___________________________________________________________
od of military member’s covered active duty: __________________________________________________________
A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written
documentation confirming a military member’s covered activedutyor call to covered active duty status. Please check one
of the following and attach the indicated document to support that the military member is on covered active duty or call to
covered active duty status.
A copy of the military member’s covered active duty orders is attached.
Other documentation from the military certifying that the military member is on covered active duty (or has been
notified of an impending call to covered active duty) is attached.
I have previously provided my employer with sufficient written documentation confirming the militarymember’s
covered active duty or call to covered active duty status.
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PART A:QUALIFYING REASON FOR LEAVE
1.Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you
are requesting leave):
2.A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes
any available written documentation which supports the need for leave; such documentation may include a copy of
a meeting announcement for informational briefings sponsored by the military; a document confirming the military
member’s Rest and Recuperation leave; a document confirming an appointment with a third party, such as a
counselor or school official, or staff at a care facility;or a copy of a bill for services for the handling of legal or
financial affairs. Available written documentation supporting this request for leave is attached.
PART B: AMOUNT OF LEAVE NEEDED
1. Approximate date exigency commenced: __________________________________________________________
Probable duration of exigency: __________________________________________________________________
2. Will you need to be absent from work for a single continuous period of time due to the qualifying exigency?
If so, estimate the beginning and ending dates for the period of absence:
3. Will you need to be absent from work periodically to address this qualifying exigency? Yes
Estimate schedule of leave, including the dates of any scheduled meetings or appointments:
Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time
, 1 deployment-related meeting every month lasting 4 hours):
Frequency: _____ times per _____ week(s) _____ month(s)
Duration: _____ hours___ day(s) per event.
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If leave is requested to meet with a third party (such as to arrange for childcareor parental care, to attend counseling, to
attend meetings with school, childcareor parental careproviders, to make financial or legal arrangements, to act as the
military member’s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing
military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and
sufficient certification includes the name, address, and appropriate contact information of the individual or entity with
whom you are meeting (
, either the telephone or fax number or email address of the individual or entity).This
information may be used by your employer to verify that the information contained on this form is accurate.
Name of Individual: ______________________________ Title: ______________________________________________
Telephone: (________) ___________________________ Fax: (_______) ______________________________________
Describe nature of meeting: ___________________________________________________________________________
I certify that the information I provided above is true and correct.
Signature of Employee ___________________________________________ Date _______________________________
PAPERWORK REDUCTION ACT NOTICE AND PUB LIC BURDEN ST ATEMENT
If submitted, it is mandatory for employersto retain acopy of this disclosurein their records for three years. 29U.S.C.2616; 29CFR825.500.
Personsare notrequired to respond to this collection ofinformation unless itdisplays acurrently valid OMB control number. The Department
of Laborestimates that it will take an average of 20 minutes for respondents to complete this collection of information, including the time for
reviewing instructions, searching existing data sources, gatheringand maintaining the data needed, and completing and reviewing the collection
of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including
suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200
Constitution AV, NW, Washington, DC 20210. DO N OT SEND THE CO MPLETED FORM TO THE WAGE AND HOUR DIVISION;
RETURN IT TO THE EMPLOYER.