Approved_-_Attachment_4_-_Bereavement_Certification.rtf

ATTACHMENT 4

SOLICITATION: HDEC08-13-R-0004

ATTACHMENT 4

BEREAVEMENT LEAVE CERTIFICATION

REQUEST FOR PAYMENT

Contract Number:________________________________________________________

Store Locations: _________________________________________________________

Name of Employee:_______________________________________________________

Area of Operation (circle one): Shelf Stocking / Custodial / RSHA

Name of Deceased:_______________________________________________________

Relationship to Employee:_________________________________________________

Dates of Bereavement Leave:_______________________________________________

I certify that the above named individual took Bereavement Leave in accordance with the provision of the Collective Bargaining Agreement (CBA) applicable to abovementioned contract and that the individual was paid according to its provisions. Pursuant to said agreement, the contractor is entitled to reimbursement.