ADDITIONAL PATERNITY LEAVE (ADOPTION) DECLARATION FORM
To be completed by the University of Warwick employee
Name of employee:
Employee ID:
Job Title:
In respect of my request to take additional paternity leave, and to receive additional statutory paternity
pay (if applicable), I confirm that (please tick one box):
I am the child’s father
I am not the child’s father, but am married to, the partner or the civil partner of the
child’s mother
In addition, I confirm that (please tick each box that is applicable):
I have, or expect to have, the main responsibility (apart from the main adopter’s
responsibility) for the upbringing of the child
The purpose of the period of my additional paternity leave will be to care for the child,
and I intend to care for the child during the additional statutory paternity pay period
The information that I have provided in my request to take additional paternity leave, is
correct
UK adoption only
The date on which we were notified of having been matched
with the child was
UK adoption only
The date on which the child was placed was
Overseas adoption only
The date on which the official notification was received was
Overseas adoption only
The date of the child’s entry into the UK was
Notification of Additional Paternity leave dates
The name and address of the adoption agency
The date I wish to start additional paternity leave is
The date I intend to return to work following additional paternity leave is
I consent to the University of Warwick processing the information that is contained in this form, and
contacting my child’s adopter’s employer so that they can verify the information.
Signed:
Dated:
To be completed by child’s main adopter
Name of child’s adopter:
Name of adopter’s employer:
Address of adopter’s employer:
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ADDITIONAL PATERNITY LEAVE (ADOPTION) DECLARATION FORM
Adopter’s national insurance number:
I, the child's adopter have now given notice to my employer that I am returning to work from my
adoption leave and the relevant details are as follows:
I became entitled, by reference to adopting my child, to statutory adoption pay
The start date of my statutory adoption pay period, in respect of my child was:
I intend to return to work from my adoption leave on:
I confirm that the employee named above is
My child’s adopter
In addition, I confirm that (please tick each box as appropriate):
He/she has, or expects to have, the main responsibility (apart from my responsibility)
for the upbringing of my child
The employee is, to my knowledge, the only person exercising the entitlement to
additional paternity leave, and is the sole applicant for additional statutory paternity
pay, in respect of my child
I consent to the University of Warwick processing the information that is contained in this form, and
contacting my employer so that they can verify the information.
Signed:
Dated:
Notes
To qualify for additional paternity leave and pay, the employee must return this form to their link HR Adviser
not less than eight weeks before the start date chosen by him/her for additional paternity leave and pay.
A partner is a person, whether of a different sex or the same sex, who lives with the mother and the child in an
enduring family relationship but is not a relative of the mother. A "relative" for these purposes includes the
mother’s parents, grandparents, sisters, brothers, aunts and uncles.
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