Sick and Family Leave Tax Credit Claim Form

Sick and Family Leave Tax Credit Claim Form
Submit your claim for tax credits related to sick or family leave provided to employees. Please complete all relevant sections and attach supporting documentation.
Claimant Full Name
First NameLast Name
Business/Employer Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Employee Name (for whom leave was provided)
First NameLast Name
Type of Leave
Reason for Leave
Leave Start Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Leave End Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Total Number of Leave Days Claimed
Total Amount of Credit Being Claimed (USD)
Upload Supporting Documentation (e.g., payroll records, leave request forms)
Cancelof
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