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Age of Family Members (if applicable): Enter one: Number of Family Members (if applicable): Enter the range of numbers and the numbers should be between 1 and 4 if possible. The maximum number of family members for which a request can be made is 4. (Number of hours spent caring for the family member(s) during such leave period) (Entering 2) Number of Hours of Care Spent (Entering 2) Name/Job Title: Please type the appropriate information. This information is required to complete this request. Employer Identification Number: Employee #: Relation to Employee: Employee name is not part of the Employer's identification number. Note: If the Employer information on the certification form is incorrect or is incomplete, please be sure to follow your HR professional's instructions for updating the identification. Note: Incomplete, wrong, duplicate or misleading responses will result in denial of the certification. Employee's name: Note: If the employee provided the employee name on a previous FMLA certification form, the employee's name is required to be included on this request when the employee requests Family and Medical Leave for this purpose. Employee's Last Name: Date of Birth: Relation to Employee: Spouse Child Note: Date of birth should be given in the format MM/DD/YYY Date of Birth is not required if Family Leave is requested for a condition related to pregnancy(s) or in which the employee is not pregnant at the time of request. Last 4 digits of Social Security #: Relation to Employee: Child Parent Employee #: Relation to Employee: Spouse Age: Enter the range of numbers between 13 and 25 to indicate the age of the family member. If the last four digits do not match the Employee #, the last four digits should be entered in place of Employee #. Note: All requests for Family and Medical Leave for a child or for adult dependents must be made within three (3) years of leaving the employee's employment. The employee may request only one Family and Medical Leave for a child or adult dependent. An employee who is caring for a family member who is more than 3 years of age at the time of certification may request Family and Medical Leave for the other family member(s) who is less than three (3) years of age. Note: An employee can request this leave for a family member only after the employee has entered the FMLA disability status on a certified medical certificate with his/her supervisor.