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<br /> Form FMLA-4 <br />CITY OF PARIS <br />FAMILY AND MEDICAL LEAVE <br />SUPERVISOR’S FORM <br /> <br /> <br />TO BE COMPLETED BY SUPERVISOR AND PROVIDED TO THE EMPLOYEE <br />Name of Employee____________________________________Department:________________________ <br /> <br />This is to inform you that: <br /> <br /> <br />You are eligible are not eligible for leave under the FMLA. <br />?? <br /> <br />The leave that you are taking will will not be counted against your annual FMLA leave entitlement. <br />?? <br />You will will not be required to furnish a medical certification of a serious health condition by <br />?? <br />______________________. If certification is not received within 15 days of receiving this notice, <br />we may delay the commencement of your leave until certification is received. <br />You will be required to substitute accrued sick and vacation leave for unpaid FMLA leave. <br />You will will not be required to furnish us periodic reports every______________________. <br />?? <br />You will will not be required to present a fitness-for-duty certificate prior to being restored to <br />?? <br />employment. If such certification is required but not received, you will not be allowed to return to <br />active duty. <br /> <br />If you are on paid leave, your insurance premium will continue to be deducted from your salary warrant. <br />If you are on unpaid leave, you should submit your portion of your insurance premium to the Finance <br />st <br />Department no later than the 1 of each month. <br /> <br /> <br /> <br />Your Family and Medical Leave will begin (m/d/yy)___________________and end <br />on________________ <br />Your FMLA unpaid leave begins (m/d/yy)___________________________________________________. <br />_________________________________________________ <br />Signature of Supervisor Date <br />_________________________________________________ <br />Signature of Dept. Head Date <br /> 69 <br /> Revised: 3/1/2006 <br /> <br />