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Documents needed to complete your paid family and medical leave (PFML) application

When you apply for PFML, you will be asked to provide documents to verify the information included in your application.

When you apply for medical and family leave, you’ll need to provide some information about your situation so we can verify the details of your application. Here is a list of specific documents, forms, and other materials you will be asked to provide copies of as part of your paid family or medical leave application.

Please provide color copies of identity verification documents. Please do not send the Department original documents - they will not be returned to you.

Only PDF and image files (.jpg, .jpeg, .png) are accepted. Files must be smaller than 3.5 MB.

Table of Contents

For Medical Leave

Continuous leave

If you are taking continuous leave, you should provide a Massachusetts Certification of a Serious Health Condition Form filled out by your health care provider that includes the following information: 

  • A statement that you have a serious health condition (Certification of a Serious Health Condition Form Questions #16 & #17)  

  • The date on which your serious health condition started (Form Question #19) 

  • The probable duration of your serious health condition (Form Questions #24, #25, #26, #29 #30 (Part 5A)) 

  • A certification that you can’t work due to the serious health condition (Form Questions #27 & #28) 

Intermittent leave

For intermittent or reduced paid leave applications, include a Massachusetts Certification of a Serious Health Condition Form filled out by your health care provider that includes the following information: 

  • A statement that you have a serious health condition (Form Questions #16 & #17) 

  • The date on which your serious health condition started (Form Question #19) 

  • The probable duration of your serious health condition (Form Questions #24, #25, #26 & based on answer to #26 the applicable Section 5B and/or 5C) 

  • A certification that you can’t work due to the serious health condition (Form Questions #27 & #28) 

  • Information about the need for intermittent leave, including a statement why the schedule is medically necessary (Form Question #18 Part 5B and/or Part 5C) 

For Family Leave

Family leave to care for a family member with a serious health condition

To be approved for family leave to care for a family member, we’ll need to confirm your relationship to your family member and their serious health condition. To do this, you’ll need a Massachusetts Certification of a Serious Health Condition Form filled out by your family member’s health care provider that includes the following information: 

  • The name and address of your family member (Certification of a Serious Health Condition Form Questions #11, #12, #13) 

  • Your relationship to the family member with a serious health condition (Form Question #10) 

  • A statement from your family member’s health care provider that they have a serious health condition (Form Questions #16 & #17) 

  • The date on which the family member's serious health condition started (Form Question #19) 

  • The probable duration of the family member's serious health condition (Form Questions #24 & #25) 

  • A statement from the health care provider that you are needed to care for the family member (Form Question #23) 

  • An estimate regarding the frequency and the anticipated duration of time that you are needed to care for the family member (Form Questions #24, #25, #26 & based on answer to #26 the applicable Section 5A, 5B or 5C)  

  • Information as required by Department proving identity of your family member (Form Questions #14 & #15) 

 

Family leave to bond with a newborn child

In order to be approved to take family leave to bond with a newborn child, we’ll need to know the child’s date of birth. You can use copies of any of the documents below:

  • The child's government-issued birth certificate, or 

  • A statement from the child's health care provider stating the child's birth date, or 

  • A statement from the health care provider of the person who gave birth stating the child's birth date, or 

  • A statement or Birth Record from the hospital where the child was born indicating the child’s birth date and signed by the Birth Registrar. 

 

Family leave to bond with a newly adopted child or a child recently placed in foster care

To be approved to take family leave to bond with a newly adopted child or a child recently placed in foster care, we’ll need to verify the child’s placement in your care and the date of their placement. You can use copies of any of these documents:

  • A certificate from the child's health care provider confirming both the placement of the child AND date of placement, or

  • A certification from an adoption or foster care agency involved in the placement confirming both the placement of the child AND date of placement, or

  • A certificate from the Department of Children and Families confirming both the placement of the child AND the date of the placement.

 

Family leave to care for a family member who is a covered servicemember

Those applying for family leave to care for a family member who is a covered service member should include in their application a Massachusetts Certification of a Serious Health Condition Form that includes the following: 

  • The date on which the covered service member's serious health condition began (Form Question #19) 

  • The probable duration of the condition, (Form Questions #24 & #25) 

  • A statement from health care provider that the covered individual is needed to care for the family member (Form Question #23) 

  • An estimate of the amount of time the covered individual will be needed to care for the family member (Form Questions #24, #25, #26 & based on answer to #26 the applicable Section 5A, 5B or 5C)  

  • Your familial relationship of the covered service member (Form Question #10) 

  • Attestation by the service member's health care provider and the covered individual that the health condition is connected to the service member's military service (Form Question #22) 

  • Information as required by Department proving identity of family member (Form Questions #14 & #15) 

  • The name and address of the family member (Form Questions #11, #12, #13) 

 

Family leave to manage affairs while a covered servicemember is or will be deployed overseas

When applying to manage affairs when a family member who is a covered service member is being deployed overseas, you should include copies of documents that prove the following:

  • The dates or period of time for which your leave is required  

  • The underlying reason for your leave 

  • Your familial relationship with the service member

  • The name and address of the family member being cared for 

  • Information as required by Department proving identity of family member who is or will be deployed overseas

And a copy of one of the following certification documents: 

  • A copy of the family member's active duty orders 

  • A letter of Impending Activation from the family member's Commanding Officer 

  • An FMLA WH-384 form

Documents to prove your or or your family member’s identity

No matter what type of leave you apply for, you will need to prove your identity. For family leave, you will also need to prove the identity of your family member. The easiest way to do that will be to provide a color copy of your Massachusetts Driver’s License or ID card, but there are other options available if you do not have one.

To prove an identity we will need:

A copy of one of the following in color: 

  • Massachusetts REAL ID or MA Driver's License, or

  • Massachusetts ID Card 

 

For Non-Massachusetts ID holders

A copy of one of the following in color: 

  • A valid, unexpired U.S. State or Territory Real-ID License or ID, or 

  • A valid, unexpired U.S. passport or passport card, or  

  • A valid, unexpired Permanent Resident Card (Form I-551) issued by the U.S. Department of Homeland Security (DHS) or the U.S. Immigration and Naturalization Service, or 

  • An employment Authorization Document issued by DHS, Form I-766, or Form I-688B, or  

  • A valid, unexpired foreign passport AND a work visa as defined by the U.S. Department of State 

If you don’t have any of the options above, you’ll need one to upload color copies of 2 documents: one to prove your legal ability to live and work in the U.S., and one to check your social security number (SSN) or Individual Tax Identification number (ITIN). 

To demonstrate your legal ability to live and work in the U.S., you can use a color copy of any one of these documents: 

  • A valid, unexpired U.S. State or Territory License or ID (not marked for federal Real-ID compliance) 

  • A certified copy of your birth certificate filed with a State Office of Vital Statistics or equivalent agency in your state of birth. (A Puerto Rican birth certificate will only be accepted if it was issued on or after July 1, 2010. For more information on the Puerto Rican birth certificate law, visit the Puerto Rico Federal Affairs Administration.

  • A certificate of Citizenship, Form N-560, or Form N-561, issued by the Department of Homeland Security

  • A certificate of Naturalization (Form N-550 or N-570) 

You can then provide proof of your 9-digit SSN or your ITIN using a copy of one of the following documents:

  • An SSN Card

  • A W-2 Form

  • An SSA-1099 Form

  • A Non-SSA-1099 Form

  • A pay stub with your full name and SSN on it

  • An authorization letter from the IRS displaying your 9-digit individual tax identification number

No matter which option or options you choose to use, you must include both the front and back of the document for it to be accepted. Document copies must be in color to be accepted.

Contact

Phone

For questions about benefits and eligibility: (833) 344-7365

Department of Family and Medical Leave - Hours of operation: Monday-Friday, 8 a.m - 5 p.m.

Fraud Reporting Hotline: (857) 366-7201

Department of Family and Medical Leave - Hours of operation: Monday-Friday, 8 a.m - 5 p.m.

For questions about contributions and exemptions: (617) 466-3950

Department of Revenue - Hours of operation: Monday-Friday, 9 a.m. - 4 p.m.

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