FMLA Form -- Attestation of In Loco Parentis Relationship ...



ATTESTATION OF

IN LOCO PARENTIS RELATIONSHIP

Please complete this form if you seek leave under the Family and Medical Leave Act (“FMLA”) to care for a child who is not legally or biologically related to you.

STATE OF NORTH CAROLINA

COUNTY OF ORANGE

My name is _________________________________________ and my P.I.D. number is

Your full name

_______________________. I am of sound mind and fully capable of executing this Attestation

of In Loco Parentis Relationship.

I attest under oath that I stand in loco parentis (have assumed the role of a parent) to

_________________________________________ (hereinafter “Child”), who is either (i) under

Name of Child

eighteen (18) years of age or (ii) eighteen (18) years of age or older and incapable of self-care

because of a mental or physical disability, and that I provide or intend to provide day-to-day care

for Child and/or financial support to Child.

Pursuant to the Family and Medical Leave Act (“FMLA”), I seek leave due to (a) the

birth of Child and in order to care for such Child; (b) the placement of Child for adoption or

foster care; or (c) to care for Child, who has a serious health condition.

This ________ day of ______________________, 20_____.

__________________________________________

Signature

Sworn to and subscribed before me

this ______ day of _______________, 20______.

_______________________________________

Notary Public

My Commission Expires: ___________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download