ࡱ> %` bjbj {̟̟r    T T T h mmm8(nnh wJp<wwwwxR~%+HXh$h)T xx  ww1___ 8wT w___< T _wp w(m__ G0w_բzբ_բT _>,_$?dwh h h 2 =0h h h =h h h         STATE OF IOWA Servicemember Family Leave Application TO BE COMPLETED BY EMPLOYEE AND PERSONNEL ASSISTANT (please print or type) Employee Name: FORMTEXT      SSN: FORMTEXT      Department: FORMTEXT      Payroll No.: FORMTEXT      Bargaining Unit: FORMTEXT      Status: FORMTEXT       My spouse is employed by the State of Iowa (check one):  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, name the department and verify the number of FMLA hours used during fiscal year (if any):  FORMTEXT        PERIOD OF SERVICEMEMBER LEAVE: FROM: FORMTEXT      TO: FORMTEXT      (Date - must be included to process your application)(Date - if known, indicate if unknown) CHECK THE APPROPRIATE BOX:  FORMCHECKBOX  CARE OF A COVERED SERVICEMEMBER (26 WEEK MAXIMUM)  (Servicemember s serious health condition) Servicemember Name:  FORMTEXT      Relationship:  FORMTEXT        FORMCHECKBOX  QUALIFYING EXIGENCY LEAVE (12 WEEK MAXIMUM PER FISCAL YEAR) Servicemember Name:  FORMTEXT      Relationship:  FORMTEXT       Reason for Leave:  FORMTEXT        Certification of physician or practitioner must accompany this form, except in the case of a qualifying exigency. However, completion of this form is required. You may be required to supply further documentation.I understand that during Servicemember Family Leave, I am required to pay my share of insurance premiums for which I am ordinarily responsible. If premiums are not paid within 30 calendar days of the coverage month, my insurance will be retroactively canceled. I acknowledge that, if I do not return from leave due to reasons not provided in the Family and Medical Leave Act, I am required to reimburse any premiums paid by the State of Iowa for my insurance while I am on approved Servicemember Family Leave. If reimbursement is not made, insurance coverage will be canceled retroactively to the first of the month following exhaustion of paid leave. I intend to return to work (check one):  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unknown Your signature certifies that you have read and understand the information on this form. Employee Signature:Date:  FORMTEXT      Supervisor Approval:Date:  FORMTEXT      Personnel Assistant Verification:Date:  FORMTEXT      Personnel Assistant Telephone Number: ( FORMTEXT      )  FORMTEXT       CFN 552-0724 6/08 Page  PAGE 1 of  NUMPAGES 2 EXTENSION of Request (if maximum leave per fiscal year is not exhausted). Additional Information May Be Required: From: FORMTEXT      To: FORMTEXT      (Date)(Date)Employee Signature:Date: FORMTEXT      The employee named is granted the extension of Servicemember Family Leave requested. All stated information remains accurate.Supervisor Signature:Date: FORMTEXT       TRACKING To be completed by the personnel assistant (please print or type) 1.FMLA leave used to date: FORMTEXT      (If employee has previously been approved for FMLA leave during the current fiscal year, enter the number of hours previously utilized [from (6) on last FMLA leave tracking form].) 2.Last date worked:  FORMTEXT      2a. FMLA start date:  FORMTEXT      (Enter the last date the employee was actively working and the date FMLA leave started.) 3.Last date in paid status:  FORMTEXT      3a. Hours of paid FMLA leave:  FORMTEXT      (Enter the last date the employee was in pay status [if applicable] and the total hours of paid FMLA leave.) 4.Returned to work:  FORMTEXT      4a. 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(Enter the total hours of unpaid FMLA leave [if applicable]). 5.FMLA leave expired:  FORMTEXT      (If the employee did not exhaust the 12 week maximum, go to number six. If the employee did exhaust the 12 week maximum, enter the date and hour in which it terminated [see calculation worksheet below to determine the maximum number of hours available per fiscal year].) 6.Total FMLA leave used:  FORMTEXT      (Enter the total number of FMLA leave hours [paid and unpaid] used this fiscal year.)  FORMTEXT      X12= FORMTEXT      (Average Number of Hours Per Week)(weeks)(Total Number of FMLA Leave Hours Available) NOTE: If average number of hours per week is under 30, the employee is not eligible for life and disability insurance. If average number of hours per week is under 20, the employee is not eligible for health and dental insurance. PLEASE USE THE TABLE BELOW TO TRACK FMLA LEAVE USAGE Pay PeriodHours WorkedFMLA Leave Used This Pay PeriodFMLA Leave Used This Fiscal Year FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       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