The care of your newborn child, or the placement of a child with you for adoption or foster care; or

Date: Dear Employee: We have been notified of your request to take a leave of absence (LOA) for: A serious health condition (including incapacity due to pregnancy) that makes you unable to perform the essential functions of your job; or A serious health condition affecting a family member for whom you are needed to provide care; or The care of your newborn child, or the placement of a child with you for adoption or foster care; or To perform certain obligations, including attending military events, arranging alternative childcare, addressing certain financial and legal arrrangements, attending certain counseling sessions, attending reintegration briefings, or addressing other qualifying exigencies arising from the active duty or call to active duty status of your spouse, son, daughter, parent or To care for a family member who has a serious injury or illness incurred in the line of duty while on active duty or re-aggravated while on active duty, and for which he or she is undergoing medical treatment, recuperation, or therapy; or is otherwise in outpatient status; or otherwise on the temporary disability retired list, who is currently a member of the Armed Forces, including a member of the National Guard or Reserves or a veteran who was a member of the Armed Forces, National Guard or Reserves within five years of the date of the medical treatment, recuperation, or therapy, During the leave determination process, MetLife may administer your leaves of absence (paid and unpaid) under the Family and Medical Leave Act (FMLA) and state leave laws Your eligibility and your reason for leave are being evaluated to determine whether or not this leave qualifies under each category If approved, your leave of absence will be counted against your annual entitlement under the FMLA and/or other leave categories The following information is enclosed in your employee packet: Your Rights and Obligations under the Family and Medical Leave Act Special Notice for Individuals Working in California Special Notice for Individuals Working in District of Columbia Authorization to Disclose Information about Me Proof of Relationship if your LOA is for the care of your newborn child, a copy of the child s birth certificate or hospital discharge record if your LOA is for the placement of a child with you, a copy of the foster care or adoption placement record or certificate Health Care Provider Certification (HCPC) You must have this form completed by your health care provider or your family member s health care provider and returned to your employer if: Your request for leave is due to the serious health condition of a family member rather than yourself; or Your request for leave is due to your own serious health condition and you are not making a claim, or you are ineligible, for disability benefits* under your Employer s disability plan If you are making a claim for disability benefits, the medical documentation submitted in support of your disability claim will be reviewed for the purpose of determining your leave request under the FMLA and/or other leave categories*

Your Certification of Qualifying Exigency for Military Family Leave HCPC of Serious Injury or Illness of Covered Service-member If you are requesting leave to care for a covered servicemember who has a serious injury or illness incurred in the line of duty while on active duty, you must have this form completed by: a United States Department of Defense ( DOD ) Health Care Provider or a, health care provider who is either, (1) a United States Department of Veterans Affairs ( VA ) health care provider; (2) a DOD TRICARE network authorized private health care provider; or (3) a non-network TRICARE authorized private health care provider, and return to your employer You must have the above required forms completed and returned to your employer by the beginning of your absence or within 15 calendar days of the date of this letter (whichever is later) or your leave request may be delayed or denied * You may choose not to pursue your disability claim under your Employer s disability plan and still have your request for a leave of absence considered for FMLA and/or other categories

SPECIAL NOTICE FOR INDIVIDUALS WORKING IN CALIFORNIA FAMILY CARE AND MEDICAL LEAVE (CFRA Leave) AND PREGNANCY DISABILITY LEAVE (PDLA Leave) Under the California Family Rights Act of 1993 (CFRA), if your employer has 50 or more employees, you work at a location in California where your employer has at least 50 employees within a 75 miles radius, you have more than 12 months of service with your employer, and you have worked for your employer at least 1,250 hours in the 12-month period before the date you want to begin your leave, you may have a right to an unpaid family care or medical leave (CFRA leave) This leave may be up to 12 workweeks in a 12-month period for the birth, adoption, or foster care placement of your child or for your own serious health condition or that of your child, parent or spouse Even if you are not eligible for CFRA leave, if disabled by pregnancy, childbirth or related medical conditions, you are entitled to take a pregnancy disability leave of up to four months, depending on your period(s) of actual disability If you are CFRA-eligible, you have certain rights to take BOTH a pregnancy disability leave and a CFRA leave for reason of the birth of your child Both leaves contain a guarantee of reinstatement to the same or to a comparable position at the end of the leave, subject to any defense allowed under the law If possible, you must provide at least 30 days advance notice for foreseeable events (such as the expected birth of a child or a planned medical treatment for your self or of a family member) For events which are unforeseeable, you must notify your employer, at least verbally, as soon as you learn of the need for the leave Failure to comply with these notice rules is grounds for, and may result in, deferral of the requested leave until you comply with this notice requirement Your employer may require certification from your health care provider before allowing you a leave for pregnancy or your own serious health condition or certification from the health care provider of your child, parent, or spouse who has a serious health condition before allowing you a leave to take care of that family member MetLife or your employer will (or has) informed you that such certification is necessary When medically necessary, leave may be taken on an intermittent or a reduced work schedule If you are taking a leave for the birth, adoption or foster care placement of a child, the basic minimum duration of the leave is two weeks and you must conclude the leave within one year of the birth or placement for adoption or foster care Taking a family care or pregnancy disability leave may impact certain of your benefits and your seniority date In addition, the federal Family and Medical Leave Act (FMLA) and your employer s policies may give you other rights and/or result in other limitations and requirements If you want more information regarding your eligibility for a leave and/or the impact of the leave on your seniority and benefits, please contact your employer

SPECIAL NOTICE FOR INDIVIDUALS WORKING IN THE DISTRICT OF COLUMBIA FAMILY AND MEDICAL LEAVE Under the District of Columbia Family and Medical Leave laws, if you work at a location in the District of Columbia where your employer has 20 or more employees in the District, you have more than 1 year of continuous service with your employer, and you have worked for your employer at least 1,000 hours in the 12-month period before the date you want to begin your leave, you may have a right to an unpaid family or medical leave An eligible employee may take unpaid family leave for up to 16 workweeks in a 24-month period, if necessary, for the birth, adoption, or foster care placement of a qualifying child or to care for a qualifying family member who has a serious health condition Under DC Family and Medical Leave Laws, a family member is defined as someone to whom the employee is related by blood, legal custody or marriage; a child living with the employee for whom the employee permanently assumes and discharges parental responsibility; or a person who lives with the employee with whom the employee maintains a committed relationship If you are taking a leave for the birth, adoption or foster care placement of a child, the leave must conclude within one year of the birth or placement for adoption or foster care An eligible employee may take medical leave for up to 16 workweeks in a 24-month period, if necessary, for an employee who is unable to perform the functions of his/her position because of their own serious health condition If you are eligible, you have certain rights to take family and/or medical leave Both leaves contain guarantee of reinstatement to the same or to a comparable position at the end of the leave, subject to any defense allowed under the law If possible, you must provide reasonable advance notice for foreseeable events (such as the expected birth of a child or a planned medical treatment for your self or of a family member) For events which are unforeseeable, you must notify your employer, at least verbally, as soon as you learn of the need for the leave Failure to comply with these notice rules is grounds for, and may result in, deferral of the requested leave until you comply with this notice requirement Your employer may require certification from your health care provider before allowing you a leave for pregnancy or your own serious health condition or certification from the health care provider of your qualifying family member who has a serious health condition before allowing you a leave to take care of that family member MetLife or your employer will (or has) informed you that such certification is necessary When medically necessary, leave may be taken on an intermittent or a reduced work schedule Taking a family care or medical leave may impact certain of your benefits and your seniority date In addition, the federal Family and Medical Leave Act (FMLA) and your employer s policies may give you other rights and/or result in other limitations and requirements If you want more information regarding your eligibility for a leave and/or the impact of the leave on your seniority and benefits, please contact your employer An employer may periodically ask the employee about his/her status and intent to return to work; please see the cover letter to this notice regarding requirements for submission of medical information that apply to you For more information, please contact your employer

HIPAA: This Authorization has been carefully and specifically drafted to permit disclosure of health information consistent with the privacy rules adopted and subsequently amended by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Instructions for completing the form: 1 Complete all applicable areas of the form 2 If you are the Authorized Representative, include a copy of the legal document(s) authorizing you to act on the Employee/Claimant s behalf 3 Sign this form 4 Fax or return this form as soon as possible to expedite processing of your claim retain original for your records Your refusal to complete and sign this form may affect your eligibility for benefits under your employer s disability plan Employee Name: Employee ID: Authorization to Disclose Information About Me I understand that my employer has requested that Metropolitan Life Insurance Company ( MetLife ) integrate the claim services for leave under the Family and Medical Leave Act (FMLA) and state leave laws, For purposes of determining my eligibility for disability benefits and/or my Leave Request, the administration of my employer s disability benefit plan (which may include assisting me in returning to work), and the administration of other benefit plans in which I participate that may be affected by my eligibility for disability benefits, I permit the following disclosures of information about me to be made in the format requested, including by telephone, fax or mail: 1 I permit: any physician or other medical/treating practitioner, hospital, clinic, other medical related facility or service, insurer, employer, government agency, group policyholder, contractholder or benefit plan administrator to disclose to MetLife, my employer in its capacity as administrator of its disability benefit plan, and my employer regarding my Leave Request, and any consumer reporting agencies, investigative agencies, attorneys, and independent claim administrators acting on MetLife s behalf, any and all information about my health, medical care, employment, and my claim for disability benefits and/or my Leave Request consistent with law 2 I permit MetLife to disclose to my employer in its capacity as administrator of its benefit plans and to my employer regarding my Leave Request, any and all information about my health, medical care, employment, and claim for disability benefits or Leave Request I also permit MetLife to contact any health care provider who has submitted a medical certification to MetLife in connection with my Leave Request in order to authenticate, clarify, or obtain any information missing from the certification This Authorization to Disclose Information About Me specifically includes my permission to disclose my entire medical record, including medical information, records, test results, and data on: medical care, diagnosis or surgery; psychiatric or psychological medical records, but not psychotherapy notes; and alcohol or drug abuse including any data protected by Federal Regulations 42 CFR Part 2 or other applicable laws Information concerning mental illness, HIV, AIDS, HIV related illnesses and sexually transmitted diseases or other serious communicable illnesses may be controlled by various laws and regulations I consent to disclosure of such information, but only in accordance with laws and regulations as apply to me Information that may have been subject to privacy rules of the US Department of Health and Human Services, once disclosed, may be subject to redisclosure by the recipient as permitted or required by law and may no longer be covered by those rules Your health care provider may not condition your treatment on whether you sign this authorization I understand that I may revoke this authorization at any time by writing to MetLife FMLAssist at 1300 Hall Boulevard, Bloomfield, CT 06002, except to the extent that action has been taken in reliance on it If I do not, it will be valid for 24 months from the date I sign this form or the duration of my claim for benefits and/or my Leave Request, whichever period is shorter A photocopy of this authorization is as valid as the original form and I have a right to receive a copy upon request Signature Date

Certification of Health Care Provider for Employee s Serious Health Condition (Family and Medical Leave Act) SECTION I: For Completion by the EMPLOYEE Please complete Section I before giving this form to your medical provider The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own serious health condition If requested by your employer, your response is required to obtain or retain the benefits of FMLA protections Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request Your name: First Middle Last SECTION II: For Completion by the HEALTH CARE PROVIDER Your patient has requested leave under the FMLA, Answer, fully and completely, all applicable parts Several questions seek a response as to the frequency or duration of a condition, treatment, etc Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient Be as specific as you can; terms such as lifetime, unknown, or indeterminate may not be sufficient to determine FMLA coverage Limit your responses to the condition for which the employee is seeking leave Please be sure to sign the form on the last page Provider s name and business address: Type of practice / Medical specialty: Telephone:( ) Fax:( ) Part A: Medical Facts 1) Approximate date condition commenced: Probable duration of condition: Mark below as applicable: Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? No Yes If so, dates of admission: Date(s) you treated the patient for condition: Will the patient need to have treatment visits at least twice per year due to the condition? No Yes Was the medication, other than over-the-counter medication, prescribed? No Yes Page 1 of 4

Was the patient referred to other health care provider(s) for evaluation or treatment (eg, physical therapist)? No Yes If so, state the nature of such treatments and expected duration of treatment: 2) Is the medical condition pregnancy? No Yes If so, expected delivery date: 3) Is the employee unable to perform any of his/her job functions due to the condition? No Yes If so, identify the job functions the employee is unable to perform: 4) Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such medical facts may include symptoms, diagnosis, or regimen of continuing treatment such as the use of specialized equipment): Part B: AMOUNT OF LEAVE NEEDED 5) Will the employee be incapacitated for a single continuous period of time due to his/her medical condition, including any time for treatment and recovery? No Yes If so, estimate the beginning and ending dates for the period of incapacity: 6) Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee s medical condition? No Yes If so, are the treatments or the reduced number of hours of work medically necessary? No Yes Page 2 of 4

Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: Estimate the part-time or reduced work schedule the employee needs, if any: Hour(s) per day: days per week from through 7) Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job Functions? No Yes Is it medically necessary for the employee to be absent from work during the flare-ups? No Yes If so, explain: Based upon the patient s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (eg, 1 episode every 3 months lasting 1-2 days): Frequency: times per week(s) month(s) Duration: hours or day(s) per episode ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER Page 3 of 4

Health Care Provider Signature Date Page 4 of 4

Certification of Health Care Provider for Family Member s Serious Health Condition (Family and Medical Leave Act) SECTION I: For Completion by the EMPLOYEE Please complete Section I before giving this form to your family member or his/her medical provider The FMLA permits an employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave to care for a covered family member with a serious health condition If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections Failure to provide a complete and sufficient medical certification may result in a denial of your request Your name: First Middle Last Name of family member for whom you will provide care: First Middle Last Relationship of family member to you: If family member is your son or daughter, date of birth: Describe the care you will provide to your family member and estimate leave needed to provide care: Employee Signature Date Page 1 of 5

SECTION II: For Completion by the HEALTH CARE PROVIDER The employee listed above has requested leave under the FMLA to care for you patient Answer, fully, and completely, all applicable parts below Several questions seek a response as to the frequency or duration of a condition, treatment, etc Your answer should be your best estimate based upon your medical knowledge, experience, and examination of the patient Be as specific as you can; terms such as lifetime, unknown, or indeterminate may not be sufficient to determine FMLA coverage Limit your responses to the condition for which the patient needs leave Page 3 provides space for additional information, should you need it Please be sure to sign the form on the last page Provider s name and business address: Type of practice / Medical specialty: Telephone:( ) Fax:( ) Part A: Medical Facts 1) Approximate date condition commenced: Probable duration of condition: Mark below as applicable: Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility? No Yes If so, dates of admission: Date(s) you treated the patient for condition: Will the patient need to have treatment visits at least twice per year due to the condition? No Yes Was the medication, other than over-the-counter medication, prescribed? No Yes Was the patient referred to other health care provider(s) for evaluation or treatment (eg, physical therapist)? No Yes If so, state the nature of such treatments and expected duration of treatment: 2) Is the medical condition pregnancy? No Yes If so, expected delivery date: Page 2 of 5

3) Describe other relevant medical facts, if any, related to the condition for which the patient needs care (such medical facts may include symptoms, diagnosis, or regimen of continuing treatment such as the use of specialized equipment): Part B: AMOUNT OF CARE NEEDED: When answering these questions, keep in mind that your patient s need for care by the employee seeking leave may include assistance with basic medical, hygienic, nutritional, safety or transportation needs, or the provision of physical or psychological care: 4) Will the patient be incapacitated for a single continuous period of time, including any time for treatment and recovery? No Yes Estimate the beginning and ending dates for the period of incapacity: During this time, will the patient need care? No Yes Explain the care needed by the patient and why such care is medically necessary: Page 3 of 5

5) Will the patient require follow-up treatments, including any time for recovery? No Yes Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period: Explain the care needed by the patient, and why such care is medically necessary: 6) Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery? No Yes Estimate the part-time or reduced work schedule the employee needs, if any: Hour(s) per day: days per week from through Explain the care needed by the patient and why such care is medically necessary: 7) Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job Functions? No Yes Is it medically necessary for the employee to be absent from work during the flare-ups? No Yes If so, explain: Page 4 of 5

Based upon the patient s medical history and your knowledge of the medical condition, estimate the frequency of flare-ups and the duration of related incapacity that the patient may have over the next 6 months (eg, 1 episode every 3 months lasting 1-2 days): Frequency: times per week(s) month(s) Duration: hours or day(s) per episode ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER Health Care Provider Signature Date Page 5 of 5

Certification for Serious Injury or Illness of Covered Service-member For Military Family Leave (Family and Medical Leave Act) SECTION I: For Completion by the Employee and/or the covered servicemember for whom the Employee is requesting leave (This section must be completed first before any of the below sections can be completed by a health care provider) Please complete Section I before having Section II completed Your employer requires that an employee submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a serious injury or illness or illness of a covered service-member Your response is required to obtain or retain the benefit of FMLA protected leave Failure to do so may result in a denial of an employee s FMLA request Part A: EMPLOYEE INFORMATION Name and Address of Employer (this is the employer of the employee requesting leave to care for covered service-member): Name of Employee Requesting Leave to Care for Covered Service-member: First Middle Last Name of Covered Service-member (for whom employee is requesting leave to care): First Middle Last Relationship of Employee to Covered Service-member Requesting Leave to Care: Spouse Parent Son Daughter Next of Kin Part B: COVERED SERVICEMEMBER INFORMATION 1) Is the Covered Service-member a Current Member of the Regular Armed Forces, the National Guard or Reserves? Yes No If yes, please provide the covered service-member s military branch, rank, and unit currently assigned to: Is the covered service-member assigned to a military medical treatment facility as on outpatient or to a unit established for the purpose of providing command and control of members of the Armed Forces receiving medical care as outpatients (such as medical hold or warrior transition unit)? Yes No If yes, please provide the name of the medical treatment facility or unit: 2) Is the Covered Service-member on the Temporary Disability Retired List (TDRL)? Yes No 3) Is this Covered Service member a veteran? Y or N with boxes If Y, how long has it been since the service-member was a member of the Armed Forces, National Guard or Reserves? Page 1 of 3

Part C: CARE TO BE PROVIDED TO THE COVERED SERVICEMEMBER Describe the Care to Be Provided to the Covered Service-member and an Estimate of the Leave Needed to Provide the Care: SECTION II: For completion by a United States Department of Defense ( DOD ) Health Care Provider or a Health Care Provider who is either: (1) a United States Department of Veterans Affairs ( VA ) health care provider: (2) a DOD TRICARE network authorized private health care provider; or (3) a DOD non-network TRICARE authorized private health care provider If you are unable to make certain of the military-related determinations contained below in Part B, you are permitted to rely upon determinations from an authorized DOD representative (such as a DOD recovery care coordinator) (Please ensure that Section I above has been completed before completing this section) Please be sure to sign the form on the last page Part A: HEALTH CARE PROVIDER INFORMATION Health Care Provider s Name and Business Address: Type of Practice/Medical Specialty: Please state whether you are either: (1) a DOD health care provider; (2) a VA health care provider; (3) a DOD TRICARE network authorized private health care provider; or (4) a DOD non-network TRICARE authorized private health care provider: Telephone:( ) Fax:( ) Email: Part B: MEDICAL STATUS (1) Covered Service-member s medical condition is classified as (Check One of the Appropriate Boxes): (VSI) Very Seriously Ill/Injured - Illness/Injury is of such a severity that life is imminently endangered Family members are requested at bedside immediately (Please note this is an internal DOD casualty assistance designation used by DOD healthcare providers) (SI) Seriously Ill/Injured - Illness/injury is of such severity that there is cause for immediate concern, but there is no imminent danger to life Family members are requested at bedside (Please note this is an internal DOD casualty assistance designation used by DOD healthcare providers) OTHER Ill/Injured - a serious injury or illness that may render the service-member medically unfit to perform the duties of the member s office, grade, rank, or rating NONE OF THE ABOVE (Note to Employee: If this box is checked, you may still be eligible to take leave to care for a covered family member with a serious health condition under the FMLA If such leave is requested, you may be required to complete an employer provided form seeking the same information) Page 2 of 3

(2) Was the condition for which the Covered Service member is being treated incurred in line of duty on active duty in the armed forces? Yes No (3) Approximate date condition commenced: (4) Probable duration of condition and/or need for care: (5) Is the covered service-member undergoing medical treatment, recuperation, or therapy? Yes No If yes, please describe medical treatment, recuperation or therapy: Part C: COVERED SERVICE-MEMBER S NEED FOR CARE BY FAMILY MEMBER (1) Will the covered service-member need care for a single continuous period of time, including any time for treatment and recovery? Yes No If yes, estimate the beginning and ending dates for this period of time: (2) Will the covered service-member require periodic follow-up treatment appointments? Yes No If yes, estimate the treatment schedule: (3) Is there a medical necessity for the covered service-member to have periodic care for these follow-up treatment appointments? Yes No (4) Is there a medical necessity for the covered service-member to have periodic care for other than scheduled follow-up treatment appointments (eg, episodic flare-ups of medical condition)? Yes No if yes, please estimate the frequency and duration of the periodic care: Health Care Provider Signature Date Print Health Care Provider Name Page 3 of 3

Certification for Qualifying Exigency For Military Family Leave (Family and Medical Leave Act SECTION I: For Completion by the EMPLOYEE INSTRUCTIONS to the EMPLOYEE: Please complete Section I fully and completely The FMLA permits an employer to require that an employee submit a timely, complete, and sufficient certification to support a request for FMLA leave due to a qualifying exigency Several questions in this section seek a response as to the frequency or duration of the qualifying exigency Be as specific as you can; terms such as unknown, or indeterminate may not be sufficient to determine FMLA coverage Your response is required to obtain a benefit While you are not required to provide this information, failure to do so may result in a denial of your request for FMLA leave The employer must give an employee at least 15 calendar days to return this form to the employer Your Name: First Middle Last Name of covered military member on active duty or call to active duty status: First Middle Last Relationship of covered military member to you: Period of covered military member s active duty: A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes written documentation confirming a covered military member s active duty or call to active duty Please check on of the following: A copy of the covered military member s active duty orders is attached Other documentation from the military certifying that the covered military member is on active duty (or has been notified of an impending call to active duty) is attached I have previously provided my employer with sufficient written documentation confirming the covered military member s active duty or call to active duty status Page 1 of 4

Part A: QUALIFYING REASON FOR LEAVE 1) Describe the reason you are requesting FMLA leave due to a qualifying exigency (including the specific reason you are requesting leave): 2) A complete and sufficient certification to support a request for FMLA leave due to a qualifying exigency includes any available written documentation which supports the need for leave; such documentation may include a copy of a meeting announcement for informational briefings sponsored by the military, a document confirming an appointment with a counselor or school official, or a copy of a bill for services for the handling of legal or financial affairs Available written documentation supporting this request for leave is attached Yes No None Available Part B: AMOUNT OF LEAVE NEEDED 1) Approximate date exigency commenced: Probable duration of exigency: 2) Will you need to be absent from work for a single continuous period of time due to the qualifying exigency? Yes No If so, please estimate the beginning and ending dates for the period of absence: Page 2 of 4

3) Will you need to be absent from work periodically to address this qualifying exigency? Yes No Estimate schedule of leave, including the dates of any scheduled meetings or appointments: Estimate the frequency and duration of each appointment, meeting, or leave event, including any travel time (ie, 1 deployment-related meeting every month lasting 4 hours): Frequency: times per: week (s) month (s) Part C: Duration: hours day (s) per event If leave is requested to meet with a third party (such as to arrange for childcare, to attend counseling, to attend meetings with school or childcare providers, to make financial or legal arrangements, to act as the covered military member s representative before a federal, state, or local agency for purposes of obtaining, arranging or appealing military service benefits, or to attend any event sponsored by the military or military service organizations), a complete and sufficient certification includes the name, address, and appropriate contact information of the individual or entity with whom you are meeting (ie, either the telephone or fax number or email address of the individual or entity) This information may be used by your employer to verify that the information contained on this form is accurate Name of Individual: Title: Organization: Address: Telephone:( ) Fax:( ) Email: Page 3 of 4

PART D: Describe nature of meeting: I Certify that the information I provided above is true and correct Signature of Employee Date Page 4 of 4