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Child Extended Bereavement Leave Complaint Form

CHILD EXTENDED BEREAVEMENT LEAVE ACT (CEBLA) COMPLAINT FORM 
I. EMPLOYER INFORMATION
II. EMPLOYEE INFORMATION

 

III. COMPLAINT DETAILS 
If Yes , What Were the beginning and end dates of each leave period 
    IV. CERTIFICATION & SIGNATURE : 

    Please sign and date

    I HEREBY CERTIFY that the statements herein, including attachments, are true and accurate to the best of my knowledge and belief. I understand that acceptance of this complaint by the Illinois Department of Labor does not guarantee any specific result. I authorize the Illinois Department of Labor to receive any monies paid and to mail such monies to me at my own risk.

     

     

    Demographic information

    IDOL asks for this voluntary information in order to learn more about the people who file complaints with us. Any information you provide will not be shared or used in relation to your complaint.