Form wording:
| Name of employee: |
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| Department: |
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| Start date with the Company: |
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| I declare that: |
Please tick as appropriate: |
| I am the child's biological father |
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| I am married to the child's mother |
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| I am the civil partner of the child's mother |
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| I am the cohabiting partner of the child's mother |
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| OR: |
| I am married to the person adopting the child |
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| I am the civil partner of the person adopting the child |
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| I am the cohabiting partner of the person adopting the child |
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| AND: |
| I am adopting jointly and have elected to receive statutory paternity pay and leave and not statutory adoption pay and leave |
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| I will have responsibility for the child's upbringing |
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| I will be absent from work for the purpose of caring for the child or supporting the child's mother |
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| Please state the date on which the child is due to be born/placed for adoption or, where the child has already been born/placed for adoption, the date when this occurred |
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| Signed: |
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Date: |
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When to use this document
Use this form to check that an employee meets the
statutory criteria necessary for eligibility for paternity leave and statutory
paternity pay.
Law relating to this document
Leading statutory authority
Employment Act 2002
Employment Rights Act
1996
Civil Partnership Act 2004
Civil Partnership Act 2004 (Amendments to
Subordinate Legislation) Order 2005 SI 2005/2114
Paternity and Adoption Leave
Regulations 2002 SI 2002/2788
Social Security Contributions and Benefits Act
1992
Statutory Paternity Pay and Statutory Adoption Pay (Weekly Rates)
Regulations 2002 SI 2002/2818
In order to be eligible
for paternity leave an employee must satisfy the following
criteria:
- The employee must be the father of the child or married to, the civil
partner or the partner of the child's mother, married to, the civil partner or
the partner of the child's adopter, or one of a couple jointly adopting a child,
and expect to have responsibility for the upbringing of the child.
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