Check One:


____________Section 1: POSTAL EMPLOYEE

                                              "Career" employee on the rolls, in a pay status, and in good standing with the USPS in the 334, 349, and 329 Zipcodes and has exhausted their annual and sick leave

                                              (or nearly exhausted) and is suffering from a debilitating disease , illness, or injury and , is not expected to return to duty.  (job related injury of illness does not

                                              qualify)


---------------Section 2: A DEPENDENT SPOUSE, CHILD, OR PARENT OF A POSTAL EMPLOYEE

                                                The dependent is suffering from a debilitation disease, illness, or injury and it requires the employee to take time off from work to attend to their needs and

                                                 the Postal employee has exhausted their annual leave (or nearly exhausted)



EMPLOYEE'S NAME_______________________________________________________________________________________________________________________


SOCIAL SECURITY NUMBER______________________________________________________________________________________________________________


ADDRESS:__________________________________________________________________________________________________________________________________

                         __________________________________________________________________________________________________________________________________


POSTAL POSTION:_________________________________________________________________________________________________________________________

IMMEDIATE SUPERVISOR_________________________________________________________________________________________________________________

NAME AND TELEPHONE NUMBER OF RELATIVE OR PERSON TO CONTACT FOR ADDITIONAL INFORMATION

                           _________________________________________________________________________________________________________________________________________


YOU MUST ALSO SUBMIT A COPY OF YOUR MOST CURRENT PAY STUB, THIS WILL BE REQUIRED BEFORE OUR CHECK IS ISSUED


FOR SECTION 1:  YOU ALSO MUST SUBMIT MEDICAL DOCUMENTATION WITH A DIAGNOSIS AND PROGNOSIS STATING WHETHER YOU ARE

                                          ANTICIPATED TO RETURN TO DUTY

FOR SECTION 2: YOU MUST SUBMIT CURRENT MEDICAL DOCUMENTATION WITH A DIAGNOSIS AND PROGNOSIS STATING THE EMPLOYEE IS NEEDED TO

                                         CARE FOR THE IMMEDIATE FAMILY MEMBER


EMPLOYEE SIGNATURE___________________________________________________________________________

DATE:__________________________________

PRINTED NAME AND RELATIONSHIP IF OTHER THAN EMPLOYEE MAKING REQUEST__________________________________________________________________________

MAIL TO: CARING FOR POSTAL FAMILIES, INC

                       P , O. BOX 6424

                       LAKE WORTH  FL  33466-6424