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Leave requests under the FMLA must be made in writing to the Company's Human Resources
Service Team department. FMLA Request Forms may be obtained from the Human Resource

Service Team. Checks and Balances, Inc. reserves the right, to assign FMLA status to an
employee within the provisions of the Act and with due notice.

FMLA CERTIFICATION REQUIREMENTS

We may ask employees to provide a certification regarding the need for leave. If you take leave
for your own or a family member’s serious health condition, or to care for a family member
who suffers or aggravates a serious injury or illness in military service, a health care practitioner

must complete part of this form. The certification must include a statement that the employee
is unable to perform the functions of his or her position, when the leave request is for the
employee’s own serious health condition. When the leave request is to care for a child, spouse,
or parent with a serious health condition, the certification must include a statement that the
employee is needed to care for the family member, and must include an estimate of the
amount of time the employee will be needed to provide care. If an employee requests
intermittent leave or leave on a reduced work schedule for planned medical treatment, the
certification must state the dates on which such treatment is expected to be given and the
expected duration of such treatment.

When the employee does not provide the requested certification within the time required or
fails to provide a complete and sufficient certification despite the opportunity to provide
necessary information, we may deny the employee’s request for FMLA leave.

As often as every thirty (30) days as leave continues, we may, in our discretion, require
recertification of any medical necessity for leave and/or the employee's intent to return to
work. If the employee requires medical leave beyond a single FMLA leave rolling calendar, the
employer may require the employee to provide a new medical certification in each new FMLA
leave year.

We have the right to seek a second opinion (and perhaps, a third opinion), and periodic
recertification’s. We may also ask you to provide other types of documentation, such as a copy
of active duty orders or proof of a family relationship to the person whom you will be caring for.

We may also ask you to provide a fitness-for-duty report from your doctor before you return to
work after taking leave for your own serious health condition.

Employee’s request for qualifying exigency leave is required to be supported by an appropriate
certification, i.e. copy of the military member’s active duty orders. The employee is only

required to provide this information to us once for a military member on a specific deployment.
In addition, we may request certification providing the information related to the particular
qualifying exigency for which leave is sought.
Checks and Balances, Inc. 47 1/2017

Disclaimer: This Handbook contains internal confidential propriety information. The policies can change at any time, for any
reason, without warning.