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Get IRS 9611 1997

Dates of FMLA a. Beginning Date 16. Justification for denial of FMLA b. Ending Date Provisionally approved pending medical certification. Form 9611 Rev. 7-97 No entitlement. Application for Leave Under the Family and Medical Leave Act 1. Name Please print - first last mi 2. Social Security Number 3. Position Title Series Grade 4. Purpose of Leave Check appropriate category a* Birth of a son or daughter and care of such child. 5 CFR 630. 1230a l b. Placement of son or daughter with you for adoption or foster care. 5 CFR 630. 1230a 2 c* Care of your spouse son daughter or parent who has a serious health condition* 5 CFR 630. 1230a 3 d. A personal serious health condition which prohibits you from performing the essential functions of your position* 5 CFR 630. 1230a 4 6. Anticipated Ending Date 5. Anticipated starting date 7. Please indicate below the total number of hours of each type of leave you anticipate needing for the current condition/event. a* Hours of sick leave c* Hours of leave without pay b. Hours of annual leave 8. If leave is for a medical condition is medical certification included with application Yes No 9. Additional information relevant to your application* if applicable APPROVED 10. Name 11. Title Date 12. Entitlement used for current 12 month period. Unacceptable final medical certification* Based on third option Cat* No* 20486E Department of the Treasury-Internal Revenue Service. Application for Leave Under the Family and Medical Leave Act 1. Name Please print - first last mi 2. Social Security Number 3. Position Title Series Grade 4. Purpose of Leave Check appropriate category a* Birth of a son or daughter and care of such child. Social Security Number 3. Position Title Series Grade 4. Purpose of Leave Check appropriate category a* Birth of a son or daughter and care of such child. 5 CFR 630. 1230a l b. Placement of son or daughter with you for adoption or foster care. 5 CFR 630. 5 CFR 630. 1230a l b. Placement of son or daughter with you for adoption or foster care. 5 CFR 630. 1230a 2 c* Care of your spouse son daughter or parent who has a serious health condition* 5 CFR 630. 1230a 2 c* Care of your spouse son daughter or parent who has a serious health condition* 5 CFR 630. 1230a 3 d. A personal serious health condition which prohibits you from performing the essential functions of your position* 5 CFR 630. 1230a 3 d. A personal serious health condition which prohibits you from performing the essential functions of your position* 5 CFR 630. 1230a 4 6. Anticipated Ending Date 5. Anticipated starting date 7. Please indicate below the total number of hours of each type of leave you anticipate needing for the current condition/event. 1230a 4 6. Anticipated Ending Date 5. Anticipated starting date 7. Please indicate below the total number of hours of each type of leave you anticipate needing for the current condition/event. a* Hours of sick leave c* Hours of leave without pay b. Hours of annual leave 8. If leave is for a medical condition is medical certification included with application Yes No 9. .

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