MFML Forms
Mashantucket Pequot Family and Medical Leave Law (MFML Law) Forms and Guidance
The following are select forms and guidance for the MFML Law. Answers to Frequently Asked Questions may be found under the MFML Law tab. Please contact the MERO for additional information.
Claim Forms
- Information for Claimants (Form 51-7100)
- Claim of Family or Medical Leave Violation (Form 51-7200)
- Notice of Appearance (Form 31-0001)
- Withdrawal Request (Form 51-7290)
Notice of Rights
Forms for Processing Leave Requests
(An employer may elect to use their own forms for processing leave requests as long as the forms comply with the MFML Law and regulations)
- Notice of Eligibility and Rights and Responsibilities (Form 51-6340)
- Verification of Relationship (Form 51-6350)
- Designation Notice (Form 51-6360)
- Certification of Health Care Provider for Employee’s Serious Health Condition (Form 51-6370)
- Certification of Health Care Provider for Employee Organ or Bone Marrow Donation (Form 51-6375)
- Certification of Health Care Provider for Family Member’s Serious Health Condition (Form 51-6380)
- Certification of Health Care Provider for Current Servicemember’s Serious Injury or Illness (Form 51-6391)
- Certification of Health Care Provider for Veteran’s Serious Injury or Illness (Form 51-6392)
- Certification of Qualifying Exigency for Military Family Leave (Form 6393)
Regulations & Guidance
