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S Department at the end of each pay period, regardless of whether FMLA time was taken Employee Name: Employee Identification No.: Department: Report is for Payroll Period Beginning: / / and Ending: / / Please indicate amount of FMLA leave taken each day (in increments of 15 minutes.) Month: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 I hereby certify that all hou.

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