NLMA Parental Leave Allowance
Report Form

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Note This special version of the Report Form is for Employment Insurance (EI) recipients with no other source of income during the benefit period; all others should submit the regular version of the Report Form.

Instructions Submit this form once to receive benefits under the NLMA Parental Leave Allowance. Failure to submit will result in a disruption of benefits. This form covers up to seventeen weeks (first Monday to last Sunday) and will not be accepted before the birth/placement date. Note, you must already have submitted the separate Application Form and been approved to receive the allowance.

Applicant

Name

NLMA Number

Report Start Date
(DD/MM/YY)


(Cannot be earlier than Birth/Placement Date; must be a Monday; must have already passed; cannot be earlier than October 5, 2015)

Report End Date
(DD/MM/YY)


(Must be a Sunday)

Report Duration
(Weeks)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Leave
(To update information originally submitted on Application Form, OTHERWISE LEAVE BLANK)

Child Full Name

Birth/Placement Date
(Proof may be requested; DD/MM/YY)

Leave Start Date
(DD/MM/YY)

Leave End Date
(DD/MM/YY)

Income
(Earned during reporting period, regardless when payment is received)

Source

Week Amount (CAD)
Fee for Service
(Gross amount; FFS income earned, regardless of when payment received)

Not applicable

$0.00
Academic
(Gross amount; academic-related parental leave allowances are exempt)
Not applicable $0.00
Employment Insurance (EI) Benefits
(Gross amount; $543 maximum benefit expected if salaried; waiting period/timing of benefits has no bearing)

Per Week

Other Employment Income
(Gross amount; rural retention bonuses are exempt)
Not applicable $0.00

Notes

Comments

Signature

Certification

I certify that for the duration of my benefit period, defined as the period from the Report Start Date to the Report End Date above, my sole source of income will be employment insurance (EI). I agree to notify the NLMA should this circumstance change at any time during the benefit period.


Assistance For assistance, please contact J. David Mitchell, Director, Administration & Membership at (709) 726-7424 (301), (800) 563-2003 (301) or dmitchell@nlma.nl.ca.

Newfoundland and Labrador Medical Association
164A MacDonald Dr., St. John's, NL, Canada, A1A 4B3
Telephone (709) 726-7424 | Toll Free (800) 563-2003 | Fax (709) 726-7525
E-mail nlma@nlma.nl.ca | Web www.nlma.nl.ca