Attachment_7_Bereavement_Certification_Form_-_Fort_Riley_HDEC0817R0029.docx
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- Solicitation number
- HDEC0817R0029
- Issued by
-
Defense Commissary Agency
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Attachment 7, Bereavement Certification Form for Fort Riley Commissary.
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ATTACHMENT 7
HDEC0817R0029
BEREAVEMENT LEAVE CERTIFICATION
REQUEST FOR PAYMENT
Contract Number:________________________________________________________
Store Locations: _________________________________________________________
Name of Employee:_______________________________________________________
Area of Operation (circle one): Shelf Stocking / RSHA / Custodial
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.
| _________________________________ |
| (Signature) |
| _________________________________ |
| (Name, Position, and Date) |
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