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FAMILIES FIRST CORONAVIRUS RESPONSE ACT (HR6201) LEAVE OPTIONS

  1. I am requesting to use Paid SICK leave under the Families First Coronavirus Response Act (HR 6201) for one of the following reasons (please check one):

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    You are eligible for 80 hours of paid sick time at 2/3 of your regular rate of pay without using your accruals.**

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  10. You are eligible for 80 hours of Paid sick at your regular rate of pay without using your accruals. *

  11. You are eligible for 80 hours of Paid sick at your regular rate of pay without using your accruals.*

  12. You are eligible for 80 hours of paid sick time at 2/3 of your regular rate of pay without using your accruals. **

  13. You are eligible for 80 hours of paid sick time at 2/3 of your regular rate of pay without using your accruals. **

  14. You are eligible to use your accrued paid sick time and any other accrued leave you have available until exhausted. **

  15. I will keep the Town updated of any changes.

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  17. This field is not part of the form submission.