Attachment_3_-_Bereavement_Leave_Certification.doc

Attachment 3 Commissary: Fort Lewis, WA

BEREAVEMENT LEAVE CERTIFICATION

REQUEST FOR PAYMENT

Contract:____________________________________

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)