Page 4 of 5 Fs/f PFML-CERT-FORM (12/21) Employee - First Name Middle Name Last Name Claim Number SECTION 3: Child Bonding: (Only complete if leave reason is to bond with a child) Select the type of documentation provided. Copy of Birth Certificate Healthcare provider certification (Section 2) Copy of placement documents for Adoption/Foster care SECTION 4: Military (Only complete if leave reason is for Military Exigency or Military Caregiver leave) Service Member Affiliation: Army Navy Air Force National Guard Marine Corps Other: Active Reserves Veteran Service Member Rank Unit Check all that apply Service member is on the Temporary Disability Retired List (TDRL) Service member is on the Permanent Disability Retired List Illness or Injury incurred in the line of duty Check the appropriate reason for leave Childcare and School Activities Military Events and Related Activities Short Notice Deployment Counseling Post Deployment Activities Financial and Legal Parental Care Rest and Recuperation Bereavement Additional activities as described Check one of the following and attach the indicated document to support that the military member is on covered active duty or call to covered active duty status: 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 orders (or has been notified of an impending call to active duty) in support of a contingency operation 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 in support of a contingency operation.