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Request for Leave- FMLA (Intermittent)

Please correct the field(s) marked in red below:

1
Employee's Name
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2
Department
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Department
3
Did you file a Request for Leave Under the FMLA with the City?
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Did you file a Request for Leave Under the FMLA with the City?
4
Starting date of intermittent leave.
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5
Ending date of intermittent leave.
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6
Number of FMLA-leave hours available.
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7
Number of hours of intermittent leave requested.
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8
Please state the reason(s) leave is necessary.
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9

I understand that this request for leave is a request for unpaid leave. The hours requested above will be deducted from my accrued hours of FMLA leave.

I certify that the leave requested above is for the purpose indicated on my Request for Leave Under the FMLA that I filed with the City.

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