Page 5 of 5 Fs/f PFML-CERT-FORM (12/21) Employee - First Name Middle Name Last Name Claim Number SECTION 5: Safe Leave (To be used if the employee is impacted by family violence. Complete only if filing for leave for non-medical reasons. If you have a medical reason, please file under Section 1.) Check one of the following and attach the indicated document to support your leave: Documents for a civil or criminal proceeding relating to family violence Other documentation to support your claim such as proof of care from a victim service organization or relocation due to safety Signed written statement from applicant certifying that the applicant is taking leave for one of the following reasons: 1. To obtain services from a victim services organization, 2. To relocate due to such family violence, or 3. To participate in any civil or criminal proceedings related to or resulting from such family violence. Description of the purpose for this leave (To be completed by the employee) : Third Party Signature I attest I am an Attorney, an employee of the Judicial Branch's Office of the Victim Services or the Office of the Victim Advocate, or a licensed medical professional or other licensed professional I am attesting that the applicant named in this document is a victim of family violence. Print - First Name Middle Name Last Name Organization Name Signature Date (mm/dd/yyyy) SECTION 6: How to Submit This Form Mail: MetLife Disability, P.O. Box 14590, Lexington, KY 40512-4590 Fax: 1-800-230-9531