I, [employee name], attest that I am in the process of __ adopting / __fostering a child. I am requesting leave under the Family and Medical Leave Act for time needed to fulfill prerequisites prior to the placement and for bonding leave after the placement of the child in my home. As per [company name] policy, I will provide substantiation below and as warranted throughout the placement process.
Employee Signature: ________________________________ Date: _________________
Employee Name [printed]: ___________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------
Leave start date: __________________________________________________________
Anticipated or actual placement date: _________________________________________
If leave is necessary prior to the date of adoption/foster care placement, such as for court appearances, counseling, etc., indicate the date(s) and reason(s) below:
| Date | Reason - provide brief explanation |
| | |
| | |
| | |
Documentation
| Name of adoption or foster care agency: ______________________________ Address: _________________________________ _________________________________ Contact Name: _______________________________ Phone: _____________ |
Type(s) of documentation attached / to be provided at a later date:
|
HR Use Only
| Document Received | Date |
| | |
| | |
| | |
HR Representative Signature: ___________________________________________________
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