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: ___________________
................
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