b. Process
i. Complete PFL Request Form
ii. Provide required substantiation documents
iii. Upon approval, code the time via payroll
c. Eligibility
i. All permanent employees of the City shall be eligible for benefits under the City’s PFL plan as applicable with the employees collectively bargained MOU.
ii. An employee's eligibility for the provisions of this policy terminates at midnight on the date of termination of the employer-employee relationship; or at midnight on the fifteenth day following a leave of absence without pay; or on termination of this policy.
iii. PFL military assist benefit payments are only available to eligible family members to participate in qualifying events. PFL military assist benefits are not available for the military member.
d. Benefits
i. Qualifying for PFL by:
1. Meet the City’s definition for eligibility and be covered by an applicable MOU specifying PFL benefits.
2. Take time off from work to care for a seriously ill family member, to bond with a new child or to participate in a qualifying military event.
3. Have earned at least $300 in wages from the City within the 12 months immediately preceding the PFL start date.
4. Submit your claim no later than 41 days after you begin your family leave. Do not file before your first day of leave.
ii. Benefits are payable through payroll via designated earnings/hour code. iii. Benefit Amounts
1. The minimum basic amount payable shall be no less than $50.00 per week.
2. The maximum weekly benefit amount that an employee can receive when on PFL will be $1,620 per week.
3. The maximum duration of PFL is up to eight (8) weeks.
4. If eligible, employees will receive 60% of wages for PFL.
5. These benefit amounts are available for a 12-month period, based on a rolling calendar, look back period.
iv. Waiting Period
1. Following the employee’s request to utilize the PFL benefit employees must wait seven (7) calendar days, in which time employees must provide certification of eligibility and receive approval of the request prior to receiving the benefit. Employees must use any accrued leave balances during this time.
a. Sick Leave – Subject to the provisions of the City Personnel Rules and Section 233 of the California Labor Code an
employee is entitled to supplement up to one-half (currently Item #15. Page 8
Meeting Date: 12/12/2023 / Packet Page #: 708
Policy Title – effective date
48 hours) of their annually accrued paid sick time under this policy if:
i. The leave is to attend to the illness of a child, spouse, parent, registered domestic partner or Designated
Person.
b. After exhausting the allotted sick leave, if eligible, the employee must exhaust their leave banks in the following order:
i. Administrative Leave
ii. Floating Holiday
iii. Earned Holiday
iv. Comp time
v. Vacation
2. To bond with a new child, leave can be taken anytime within the first 12 months of a child entering your family
e. Leave Balances
i. Coordination of Leave. Employees may coordinate this family leave benefit with other accrued leave balances (Vacation, Sick, Comp Time, Floating Holiday). At no time, however, shall coordination result in payment to the employee of more than one hundred percent (100%) of that employee’s “normal” base wages payable.
ii. Eligible employees not covered by FMLA or CFRA, who do not have accrued leave available to use, are not eligible to receive leave accruals. f. Probationary Period
i. If the employee was serving a probationary period at the time of a PFL period, the remainder of the probationary period must be completed. g. Health Benefits
i. PFL provides only partial wage replacement when you need to take time off work for family leave. You may have rights under other laws, such as the Family and Medical Leave Act (FMLA) or the California Family Rights Act (CFRA). The City is not required to maintain or ‘pay for’ health benefits on behalf of an employee outside of any protected leave provisions.
However, the City will continue to pay a monthly amount up to the current flexible benefit allowance in the employee's MOU for health benefits provided that the employee maintains eligibility for those benefits. The employee will be responsible for the monthly payment of any employee contributions premiums in excess of the City-paid portion while on PFL.
Insurance coverage will be dropped if employee or dependent become more than 60 days late in payment.
ii. Eligible employees not covered by FMLA or CFRA, who do not have accrued leave available to use, are not eligible to receive flexible benefit allowance.
Item #15. Page 9
Meeting Date: 12/12/2023 / Packet Page #: 709
Policy Title – effective date
h. State and Federal Taxes
i. Your PFL benefits are taxable and reportable on your federal return only.
For state taxes, PFL benefit payments are not reportable by California pursuant to Revenue and Taxation Code Section 17083.
i. Legal
If any paragraph, sentence, clause or phrase of this policy is held unlawful or invalid for any reason, said unlawfulness or invalidity shall not affect the remaining portions of this policy. Overall daily administration, application, and periodic review of this policy shall be the responsibility of the Human Resources Department.
Item #15. Page 10
Meeting Date: 12/12/2023 / Packet Page #: 710
Policy Title – effective date
Request for Paid Family Leave (PFL) Benefits - Please return this form to the Human Resources Department Part A. STATEMENT OF EMPLOYEE
Name ID
Phone Email Address
Mailing Address
City State Zip
Date you want family leave benefit to begin: Return to work date:
Reason for Requesting family leave benefit:
Care for Family Member
Bond with child
Military Assist
Do you have more than one employer?
Yes
No
Relationship of care, bonding, or military assist recipient:
Child
Spouse
Partner
Parent
Parent-in-law
Grandparent
Grand child
Sibling
Other: ____________
Do you anticipate this to be an intermittent claim? Yes No If yes, please provide further details:
DECLARATION AND SIGNATURE. By my signature on this claim statement I (1) claim Paid Family Leave benefits and certify that throughout the period covered by this claim I was providing care for, bonding with, or participating in a qualifying event with the recipient named above; (2) authorize Human Resources to release my personal information as shown on this claim to the care recipient’s treating physician as they are respectively listed in Part C and Part D of this claim; and (3) authorize release and use of information as stated in the "Information Collection and Access" portion of this form.. I declare under penalty of perjury that the foregoing statement including any accompanying statements is to the best of my knowledge and belief true correct and complete. I agree that photocopies of this authorization shall be as valid as the original and I understand that authorizations contained in this claim statement are granted for a period of fifteen years from the date of my signature or the effective date of the claim, whichever is later.
Signature Date
Item #15. Page 11
Meeting Date: 12/12/2023 / Packet Page #: 711
Policy Title – effective date
Request for Paid Family Leave (PFL) Benefits - Please return this form to the Human Resources Department PART B - BONDING CERTIFICATION (To be completed by Person Claiming PFL Benefits to Bond with a Child) EMPLOYEE SOCIAL SECURITY NUMBER: EMPLOYEE LEGAL LAST NAME:
LEGAL NAME OF CHILD:
CHILD'S GENDER:
Male Female
CHILD'S DATE OF BIRTH: (IF APPLICABLE) DATE OF FOSTER CARE OR ADOPTION PLACEMENT:
EVIDENCEOF RELATIONSHIP, CHECK ONEOF THEFOLLOWING ANDATTACH A COPY OF THE DOCUMENT CHECKED. (DO NOT SEND ORIGINAL DOCUMENT. IT WILL NOT BE RETURNED.) CHILD'S BIRTH CERTIFICATE
DECLARATION OF PATERNITY,
CS-909
FOSTER CARE PLACEMENT
RECORDS, SOC 815
INDEPENDENT ADOPTION
PLACEMENT AGREEMENT, AD-924
CERTIFICATE OF PLACEMENT, AD907
Other____________________________________________
DECLARATION AND SIGNATURE. By my signature on this bonding certification, I authorize the medical provider, adoption agency, adoption party (ies), or foster care placement agency to disclose to Human Resources Department all facts concerning the birth, adoption, or foster care placement of the abovenamed child. I understand that willfully making a false statement or concealing a material fact in order to obtain payment of benefits is a violation of California law punishable by imprisonment or fine or both. I declare under penalty of perjury that the foregoing statement, including any accompanying statements or documents, is to the best of knowledge and belief true, correct, and complete. I agree that photocopies of his authorization shall be as valid as the original, and I understand that authorizations contained in this claim statement are granted for a period of fifteen years from the date of my signature or the effective date of the claim, whichever is later.
SIGNATURE DATE
PART C - STATEMENT OF CARE RECIPIENT
(May be completed by authorized representative if care recipient is mentally or physical unable to do so. MUST be signed by care recipient or care recipient's authorized representative.)
Recipient's Date of Birth: Recipient's Telephone Number:
LEGAL NAME OF CARE RECIPIENT: RECIPIENT'S GENDER:
CARE RECIPIENT'S RESIDENCE ADDRESS:
City STATE: ZIP:
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AUTHORIZATION. I authorize any physician, practitioner, hospital, vocational rehabilitation counselor, or workers' compensation insurance carrier to furnish and disclose to my care provider, who is the claimant name and described in Part A of this claim, and to the Human Resources Department all facts concerning my condition that are within their knowledge and to allow inspection of and provide copies of any medical and billing records concerning my condition that are under their control. I understand that the Human Resources Department may disclose information as authorized by the California Unemployment Insurance Code and that such redisclosed information may no longer be protected by this rule. I agree that photocopies of this authorization shall be as valid as the original. I understand that, unless revoked by me in writing, this authorization is valid for fifteen years from the date received by the Disability & UI Department or the effective date of the claim, whichever is later. I understand that I may not revoke this authorization to avoid prosecution or to prevent the Disability & UI Department's recovery of monies to which it is legally entitled.
SIGNATURE DATE
Item #15. Page 12
Meeting Date: 12/12/2023 / Packet Page #: 712
Policy Title – effective date
Request for Paid Family Leave (PFL) Benefits - Please return this form to the Human Resources Department
DOCTOR'S CERTIFICATION MAY BE MADE BY A LICENSED MEDICAL OR OSTEOPATHIC PHYSICIAN AND
SURGEON, CHIROPRACTOR, DENTIST, PODIATRIST, OPTOMETRIST, DESIGNATED PSYCHOLOGIST, OR AN AUTHORIZED MEDICAL OFFICE OF A UNITED STATES GOVERNMENT FACILITY.
PART D DOCTOR'S CERTIFICATION
(DO NOT COMPLETE THIS PART IF REASON FOR PFL LEASE IS BONDING WITH CHILD)
CLAIMANT'S (CARE PROVIDER'S) SOCIAL
SECURITY NUMBER:
CLAIMANT'S NAME (FIRST, MIDDLE INITIAL, LAST):
PATIENT'S NAME (FIRST, MIDDLE INITIAL, LAST):
PATIENT'S DATE OF BIRTH: DOES YOUR PATIENT REQUIRE CARE BY THE CARE PROVIDER? (Yes/No) DIAGNOSIS OR, IF NOT YET DETERMINED, A DETAILED STATEMENT OF SYMPTOMS:
PRIMARY ICD CODE: SECONDARY ICD CODES: DATE PATIENT'S CONDITION COMMENCED:
FIRST DATE CARE NEEDED: DATE YOU ESTIMATE PATIENT WILL NO LONGER REQUIRE CARE BY THE CARE PROVIDER:
APPROXIMATELY HOW MANY
TOTAL HOURS:
Comments:
WOULD DISCLOSURE OF THIS CERTIFICATE TO YOUR PATIENT BE MEDICALLY OR PSYCHOLOGICALLY DETRIMENTAL? DOCTOR'S LICENSE NUMBER: STATE OR COUNTRY (IF NOT U.S.A.) IN WHICH DOCTOR IS LICENSED TO PRACTICE:
DOCTOR'S NAME (FIRST, MIDDLE INITIAL, LAST):
DOCTOR'S ADDRESS (POST OFFICE BOX IS NOT ACCEPTABLE AS THE SOLE ADDRESS):
City: State Zip
TYPE OF DOCTOR: SPECIALTY (IF ANY):
Doctor's Certification and Signature (REQUIRED): I certify under penalty of perjury that, based on my examination, this Doctor's Certificate truly describes the patient's condition and needed for care and the estimated duration thereof.
ORIGINAL SIGNATURE OF ATTENDING DOCTOR - RUBBER STAMP IS NOT ACCEPTABLE: Date:
ORIGINAL DOCUMENTS MUST BE SUBMITTED TO: City of Glendora, Human Resources Department 116 East Foothill Boulevard Glendora, CA 91741
Item #15. Page 13
Meeting Date: 12/12/2023 / Packet Page #: 713
Policy Title – effective date
Request for Paid Family Leave (PFL) Benefits - Please return this form to the Human Resources Department
PART E MILITARY ASSIST CERTIFICATION
(DO NOT COMPLETE THIS PART IF REASON FOR PFL LEASE IS BONDING WITH CHILD) CLAIMANT'S NAME (FIRST, MIDDLE INITIAL, LAST):
NAME OF THE MILITARY MEMBER ON COVERED ACTIVE-DUTY OR IMPENDING CALL TO COVERED ACTIVE-DUTY STATUS (FIRST, MIDDLE INITIAL, LAST):
MILITARY MEMBERS DATE OF BIRTH (MM/DD/YYYY) MILITARY MEMBERS GENDER
MALE FEMALE
PERIOD OF MILITARY MEMBERS COVERED ACTIVE DUTY
FROM (MM/DD/YYYY) TO (MM/DD/YYYY
DATE MEMBER WAS NOTIFIED OF COVERED ACTIVE DUTY (MM/DD/YYYY)
SELECT ONE OF THE FOLLLOWING AND ATTACH THE INDICATED DOCUMENT TO SUPPORT THAT THE MILITARY MEMBER IS ON COVERED ACTIVE DUTY OR
IMPENDING CALL OR ORDER TO COVERED ACTIVE DUTY STATUS
COVERED ACTIVE DUTY ORDERS
LETTER OF IMPENDING CALL OR ORDER TO COVERED DUTY
DOCUMENTATION OF MILITARY LEAVE SIGNED BY THE APPROVING AUTHORITY FOR MILITARY MEMBER’S REST AND RECUPERATION
THE QUALIFYING EVENT FOR THE PFL CLAIM IS TO: (ONE OR MORE REASONS MAY BE SELECTED) PROVIDE/ARRANGE CHILDCARE FOR
MILITARY MEMBER’S CHILD
ATTEND COUNSELING
ASSIST MILITARY MEMBER DURING REST
AND RECUPERATION LEAVE
REPRESENT MILITARY MEMBER AT
FEDERAL, STATE, OR LOCAL AGENCIES
PROVIDE/ARRANGE CARE FOR MILITARY
MEMBER’S PARENT
MAKE FINANCIAL/LEGAL
ARRANGEMENTS
ATTEND MILITARY EVENT
ADDRESS ISSUES DUE TO MILITARY
MEMBER’S DEATH
OTHER________________________
WRITTEN DOCUMENTION SUPPORTING THIS REQUEST FOR LEAVE IS AVAILABLE AND ATTACHED? YES
NO
NONE AVAILABLE
NOTE: A COMPLETE AND SUFFICIENT CERTIFICATION TO SUPPORT A REQUEST FOR PFL LEAVE DUE TO A QUALIFYING EVENT INCLUDES ANY AVAILABLE WRITTEN DOCUMENTATION THAT SUPPORTS THE NEED FOR LEAVE. DOCUMENTATION MAY INCLUDE; A COPY OF A MEETING ANNOUNCEMENT FOR INFORMATIONAL BRIEFINGS SPONSORED BY THE MILITARY, A DOCUMENT CONFIRMING THE MILITARY MEMBER’S REST AND RECUPERATION LEAVE, AN APPOINTMENT WITH A THIRD PARTY (I.E., A COUNSELOR, SCHOOL OFFICIAL, OR STAFF AT A CARE FACILITY), OR A COPY OF A BILL FOR SERVICES FOR THE HANDLING OF LEGAL OR FINANCIAL AFFAIRS. IF LEAVE IS REQUESTED TO MEET WITH A THIRD PARTY, THE EMPLOYEE MUST PROVIDE THE SUPPORTING
DOCUMENTATION OF THE MEETING THAT INCLUDES THE NAME, ADDRESS, AND APPROPRIATE CONTACT INFORMATION OF THE INDIVIDUAL OR ENTITY WITH WHOM YOU ARE MEETING (I.E., EITHER PHONE NUMBER, FAX NUMBER, OR EMAIL ADDRESS OF THE INDIVIDUAL OR ENTITY).
DECLARATION AND SIGNATURE. BY MY SIGNATURE ON THIS MILITARY ASSIST CERTIFICATION, I UNDERSTAND THAT WILLFULLY MAKING A FALSE
STATEMENT OR CONCEALING A MATERIAL FACT IN ORDER TO OBTAIN PAYMENT OF BENEFITS IS A VIOLATION OF CALIFORNIA LAW PUNISHABLE BY IMPRISONMENT OR FINE OR BOTH. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENT, INCLUDING ANY ACCOMPANYING STATEMENTS OR DOCUMENTS, IS TO THE BEST OF MY KNOWLEDGE AND BELIEF TRUE, CORRECT, AND COMPLETE. I AGREE THAT PHOTOCOPIES OF THIS
AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL, AND I UNDERSTAND THAT AUTHORIZATIONS CONTAINED IN THIS CLAIM STATEMENT ARE GRANTED FOR A PERIOD OF FIFTEEN YEARS FROM THE DATE OF MY SIGNATURE OR THE EFFECTIVE DATE OF THE CLAIM, WHICHEVER IS LATER.
SIGNATURE DATE (MM/DD/YYYY)
Item #15. Page 14
Meeting Date: 12/12/2023 / Packet Page #: 714