ATTACHMENT_4_-_BEREAVEMENT_LEAVE.doc

ATTACHMENT 4

BEREAVEMENT LEAVE CERTIFICATION

REQUEST FOR PAYMENT

HDEC08-16-R-0002

FORT HUACHUCA, ARIZONA

Contract Number:________________________________________________________

Store Locations: _________________________________________________________

Name of Employee:_______________________________________________________

Position (circle one):

Store Worker I / Janitor/Custodian / Material Handler / Forklift Operator & Warehouse Specialist Area of Operation (circle one): Shelf Stocking / Custodial / RSHA Name of Deceased:_______________________________________________________

Relationship to Employee:_________________________________________________

Dates of Bereavement Leave:_______________________________________________

Total Number of Hours Requested: _________________________________________

Per Paragraph 33.12 A of the CBA - Hours requested are not to exceed three (3) scheduled work days at straight time pay, pro-rated to be determined by number of hours which the employee averages during the normal work week immediately preceding the leave to begin.

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.

(Signature)

(Name, Position, and Date)

(Company)