The Essential Guide to Family & Medical Leave

appendix C | forms and checklists | 361
Form Regarding FMLA Leave to Care for a Family Member
I, have requested time off work to care for
. I have read the definitions below and I confirm
that this person qualifies as my .
I have attached a copy of the following documents confirming this relationship:
(List any documents you can provide, such as a birth certificate, papers confirming an
adoption or foster care placement, marriage certificate, and so on. If you don’t have
any documents, please write that in the space provided.)
Date:
Signature:
Definitions
Spouse: A husband or wife to whom you are legally married.
Parent: Your legal parent, or someone who had day-to-day responsibility for
supporting your financially and taking care of you when you were a child.
Child: Your biological child, adopted child, stepchild, foster child, or legal ward, or a
child whom you have the day-to-day responsibility to support financially and take
care of. Children are covered only until they reach the age of 18, unless they are
incapable of taking care of themselves because of a physical or mental disability.