Newborn & Adoption Leave Certification
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sriNewborn & Adoption Leave Certification
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sriCERTIFICATION OF NEWBORN,
ADOPTION OR FOSTER CARE
Return to Sedgwick Disability and Leave Service Center for Fidelity
Fax: (855) 284-0535 | PO Box 14487 Lexington, KY 14487
Phone: (833) 927-2632
Employee Name: Srihari Reddy Pamulapati
Claim Number: 4A2210LW96M0001GI
INSTRUCTIONS to the EMPLOYEE:
Please complete this section and provide supporting documentation for your leave. If we do not receive the
information requested may result in a denial of your request for leave under the Family and Medical Leave Act
(FMLA), applicable state leave laws, and/or company specific leaves.
It is your responsibility to ensure that the certification is provided in a timely manner.
Name of child:
First Middle Initial Last
Date child was born or placed in home: ______ / _____ / ________
Month Day Year
Begin Date of Leave: ______ / _____ / _______Expected Last Day of Leave: ______ / _____ / ________
Month Day Year Month Day Year
A complete and sufficient certification to support a request for FMLA leave due to care for a newborn, newly adopted
child, or a child placed in your custody for foster care includes written documentation confirming the child’s coverage
under FMLA. Please check one of the following:
___ A copy of the newborn child’s birth certificate or other proof of birth is attached.
___ Documentation from a state agency or other legal authority indicating the full name of the
adoptee which indicates you are the adoptive parent and the date of placement is
attached.
___ Documentation from a state agency or other legal authority indicating the full name of the foster child, that
you are authorized by the state to provide foster care services and the date of placement is attached.
I certify that the information I provided above is true and correct.
Signature of Employee Date
!T4A2210LW96M0001GI-9409!