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DECLARATION OF RELATIONSHIP For Family and Medical Leave FML This form should be completed by the employee when the employee requests FML to care for a family member with a serious health condition or for parental leave. Please note This declaration is for FML purposes only and does not establish benefits eligibility for the family member. The University may ask for reasonable documentation to confirm the family relationship referenced below. EMPLOYEE S NAME Last First Middle Initial EMPLOYEE S DEPARTMENT FOR REQUESTS FOR LEAVE TO CARE FOR A FAMILY MEMBER WITH A SERIOUS HEALTH CONDITION I am requesting FML to care for who is my and has a serious health condition* specify relationship with the employee This leave may be taken to care for the employee s spouse domestic partner child or parent. Child means a biological adopted step or foster child of the employee or a legal ward of the employee. Child also means a child to whom the employee stands in loco parentis meaning that the employee has day-to-day responsibilities to care for or financially supports the child. The child must be under 18 or incapable of self-care due to a mental or physical disability. Parent means a biological adopted step or foster parent. Parent also means a person who stood in loco parentis to the employee when the employee was a child meaning that the person had day-to-day responsibilities to care for or financially supported the employee when the employee was a child. Parent does not mean a parent in law. whose birth date was or is anticipated to be OR a child who was or will be placed in my care on This leave must be taken within 12 months of the birth or placement of the child with the employee as applicable. If leave is being taken in connection with the adoption or foster placement of a child the employee may use this leave before the actual placement or adoption if the employee s absence from work is required for the adoption or foster care placement to proceed* If the child is not yet named some description of the child should be included* SIGNATURE I Certify that the foregoing is true. Please note This declaration is for FML purposes only and does not establish benefits eligibility for the family member. The University may ask for reasonable documentation to confirm the family relationship referenced below. The University may ask for reasonable documentation to confirm the family relationship referenced below. EMPLOYEE S NAME Last First Middle Initial EMPLOYEE S DEPARTMENT FOR REQUESTS FOR LEAVE TO CARE FOR A FAMILY MEMBER WITH A SERIOUS HEALTH CONDITION I am requesting FML to care for who is my and has a serious health condition* specify relationship with the employee This leave may be taken to care for the employee s spouse domestic partner child or parent. EMPLOYEE S NAME Last First Middle Initial EMPLOYEE S DEPARTMENT FOR REQUESTS FOR LEAVE TO CARE FOR A FAMILY MEMBER WITH A SERIOUS HEALTH CONDITION I am requesting FML to care for who is my and has a serious health condition* specify relationship with the employee This leave may be taken to care for the employee s spouse domestic partner child or parent. Child means a biological adopted step or foster child of the employee or a legal ward of the employee.

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