Maternity Form B Download
Ayana Hammerschmidt
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The Department has developed optional-use forms which can be used by employers to provide required notices to employees, and by employees to provide certification of their need for leave for an FMLA qualifying reason. These forms are electronically fillable PDFs and can be saved electronically. Alternatively, employers may use their own forms, if they provide the same basic notice information and require only the same basic certification information.
Certification is an optional tool provided by the FMLA for employers to use to request information to support certain FMLA-qualifying reasons for leave. An employee can provide the required information contained on a certification form in any format, such as on the letterhead of the healthcare provider, or official documentation issued by the military.
Please do not send any completed certification forms to the U.S. Department of Labor, Wage and Hour Division. Return completed certifications to the employee to provide to his or her employer.
Your employer may use the WHD prototype forms or create their own version of the forms containing the same basic information. However, an employer that requests a medical certification may request only information that relates to the serious health condition for which the current need for leave exists, and no information may be required beyond that specified in the FMLA regulations. See 29 CFR 825.306, 29 CFR 825.307, and 29 CFR 825.308.
Employers must accept a complete and sufficient certification, regardless of the format. The employer cannot reject a certification that contains all the information needed to determine if the leave is FMLA-qualifying. The employer cannot refuse:
Yes. The content of the information contained within the optional-use DOL form is still applicable, regardless of the expiration date. The expiration date on the DOL forms is related to the collection of information as required by the Office of Management and Budget (OMB), and not relevant to the content of the required information.
If you are using screen reader software to access the form, we recommend that you review all of the notes and the questions on the form before you complete it. As you complete the form, you will be guided through the questions based on the responses you provide.
We need to know your delivery information so you can start getting Family Leave Insurance benefits for bonding after you recover from delivery. Notify us by completing the form P30 sent to you in the mail.
If planning ahead, you may start your online application up to 60 days in advance. To avoid deletion of your draft application: (1) within 14 days of starting the application, provide all information and confirm your claim; then (2) within 14 days after the start of your leave, certify and file your claim.
Applications are processed in the order they are received. Payment of benefits will be delayed if your application is incomplete or contains missing or conflicting information. You also must have your healthcare provider submit their information as soon as possible to have your application processed and any benefits paid promptly.
The Temporary Disability Benefits Law does not specify how far in advance you must notify your employer for medical leave, as many disabilities including complications during pregnancy are unforeseeable circumstances. However, we encourage you to keep your employer informed whether your leave for medical reasons is scheduled in advance or not. Having an open discussion with your employer about your need for leave will allow them to prepare for your absence and make adjustments to work schedules, if necessary. Your employer may also be able to provide insight on job protection and if you qualify for it through the Federal Family and Medical Leave Act (FMLA).
For 2022, workers contribute 0.14% on the first $151,900 (wage cap) in covered wages earned during this calendar year. The maximum worker contribution for 2022 is $212.66. This contribution is in the form of a salary deduction that your employer takes from your weekly wages.
Temporary Disability Insurance benefits are considered taxable income for purposes of both the federal income tax and FICA (Social Security). Federal income tax will not be withheld from your benefit payment each week unless you request it when you file, or submit IRS form W-4S to us (for state plan claims) or your employer (for private plan claims). Your share of FICA and medicare is automatically deducted from state plan benefit payments. Garnishments and any refunds owed from a previous disability or family leave claim will also be withheld from your benefit payments. Temporary Disability Insurance benefits are not taxed by the State of New Jersey.
The amount of your benefits that is taxable will be reported to your employer in January of the year following the receipt of your benefits. Your employer will include that information on your W-2 annual earnings statement, often listed as "third party sick pay" or "other wages." Keep in mind, benefits are federally taxable during the year that payments are issued, which may not always match up with when your leave occurred.
If your Temporary Disability benefits are not reported on your W-2, contact your employer directly to have it corrected. If needed, let your employer know they can download their year-end tax statement here. For additional information on incorrect W-2s, go to: Internal Revenue Service (IRS).
AFTER RECEIVING STATE TEMPORARY DISABILITY BENEFITS: You will receive an FL2 (new mother bonding notice) in the mail once we are notified that you delivered. The FL2 has a unique Claim ID Number on it. When you receive the form, click here and enter that number when asked. If everything goes smoothly, you should receive benefits on your debit card within two business of completing the FL2 online.
IF YOU RECEIVED PRIVATE PLAN TEMPORARY DISABILITY BENEFITS, OR NO DISABILITY BENEFITS: You will need to submit a new application for Family Leave Insurance benefits for bonding with your baby. Click here to start that process. If planning ahead, you may start your online application up to 60 days in advance. To avoid deletion of your draft application: (1) within 14 days of starting the application, provide all information and confirm your claim; then (2) within 14 days after the start of your leave, certify and file your claim. If applying after your leave begins, you have 30 days from your first day of leave to file your application.
We encourage you to keep your employer informed. Having an open discussion with your employer about your need for leave will allow them to prepare for your absence and make adjustments to work schedules if necessary. Your employer may also be able to provide insight on job protection and if you qualify for it through the federal Family and Medical Leave Act (FMLA) or the New Jersey Family Leave Act (NJFLA).
For 2023, workers contribute 0.06% on the first $156,800 (wage cap) in covered wages earned during this calendar year. The maximum worker contribution for 2023 is $94.08. This contribution is in the form of a salary deduction that your employer takes from your weekly wages.
For 2024, workers contribute 0.09% on the first $161,400 (wage cap) in covered wages earned during this calendar year. The maximum worker contribution for 2024 is $145.26. This contribution is in the form of a salary deduction that your employer takes from your weekly wages.
After the end of each calendar year, Form 1099-G will be available online for you to download and use when filing your federal income tax return. This form lists the total New Jersey State Family Leave Insurance (including Family Leave During Unemployment) benefits received that calendar year. This information is also sent to the Internal Revenue Service (IRS). If you receive Family Leave Insurance benefits from an approved private plan, your employer will provide you with the information required to file your federal income tax return. Family Leave Insurance benefits are not taxed by the State of New Jersey.
Congratulations on your pregnancy! As you may know, Massachusetts requires that Newton-Wellesley Hospital collect certain information about you, your partner and your baby. This information is confidential. During your hospital stay a Birth Registry staff member will visit you and collect the required information.
Please take care to complete this form carefully and completely as it may be difficult and costly to make corrections or changes after a birth certificate has been completed. Therefore, accuracy of information given is very important.
If you have questions about the information that is collected or problems obtaining a copy of the birth certificate from Newton City Hall, please contact the Massachusetts Registry of Vital Records and Statistics (RVRS) at 617-740-2623. Thank you for your cooperation!
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The information set forth on, and linked through, this website is designed to provide a service to the employers and employees of this state. It does not constitute legal advice. Although the Department of Labor makes every effort to provide quality information, it makes no claims, promises or guarantees about the accuracy or completeness of the information contained herein.
Please use this form to pre-register for either St. Peter's Hospital or Burdett Birth Center at Samaritan Hospital, that way when you arrive at the hospital they'll be less paperwork to deal with. Please remember to bring your ID and insurance cards.
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