Did you know that there is a certain form that needs to be filled out in order to request military funeral honors? The Form Cfn 552 0611 is the document that designates the service member's next of kin as the person who will make decisions regarding their funeral and burial. This form also authorizes reimbursement for the costs associated with military funeral honors. If you are looking for more information about how to obtain military funeral honors, or need a copy of the Form Cfn 552 0611, please visit our website.
| Question | Answer |
|---|---|
| Form Name | Form Cfn 552 0611 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | 552 0611_catastroph ic_leave_reques t internal revenue service catastrophic illness definition form |
Attachment A
STATE OF IOWA
DEPARTMENT OF ADMINISTRATIVE SERVICES – HUMAN RESOURCES ENTERPRISE
DONATED LEAVE FOR CATASTROPHIC ILLNESS
APPLICATION
Please Print or Type
Part A. TO BE COMPLETED BY THE EMPLOYEE |
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Name of Employee: |
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Social Security Number: |
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Department: |
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Payroll Number: |
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Last Date Worked: |
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Last Date in Pay Status: |
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Definition – “Catastrophic Illness” means a physical or mental illness, as certified by a licensed physician, that will result in the inability of the employee to work for more than 30 work days on a consecutive or intermittent basis.
Part B. TO BE COMPLETED BY THE PHYSICIAN (FORM WILL BE RETURNED IF NOT FULLY COMPLETED)
1. |
In your opinion, does the employee meet the “Catastrophic Illness” definition above? Yes |
No |
(Check one) |
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If no, sign and date this form. If yes, answer questions |
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2. |
Diagnosis description: |
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3. Is condition due to an injury or illness arising from your patient's employment? Yes
No
(Check one)
4. Method of treatment:
5. Has your patient been hospital confined? Yes |
No |
(Check one) Hospital name: |
6.On what date was your patient first unable to work?
7.Prognosis:
8.When could employment resume and under what conditions?
Physician's Name (Print): |
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Physician’s Signature: |
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Date: |
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Address: |
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Street |
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City & State |
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Zip Code |
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Telephone #: ( |
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Part C. TO BE COMPLETED BY THE EMPLOYER
The employee has:
•a catastrophic illness based on the physician's statement (above); and
•exhausted all paid leave; and
•been approved for or has exhausted Family and Medical Leave (FMLA); if eligible and
•been approved for medical leave without pay during any hours for which he or she will receive donated leave.
I certify that the employee meets all of the criteria as stated in Section C above.
Employer or Designee Signature |
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Date: |
Maintain the original in the employee’s confidential personnel file.
CFN