Emergency Family and Medical Leave Act (EFMLA) Request Form

HR Compliance

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This sample form can be used to document information needed from an employee requesting emergency family and medical leave under FFCRA to substantiate eligibility for tax credits, per the IRS. Retain this documentation for four years from the date of the request. While mandated benefits under FFCRA end on December 31, 2020, covered employers can voluntarily provide these benefits (if not already exhausted by employees) through March 31, 2021 and take the associated tax credit. The same daily limits and eligibility requirements apply.

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