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DECLARATION RELATIVE TO SICK LEAVE REQUEST <br /> I am requesting paid sick leave from to <br /> I declare that the illness /injury/disability for which I am requesting sick leave is bona fide and prevents <br /> me from performing my assigned duties. My absence from work was not related to a labor dispute <br /> with the County of Alameda or any department or officer or agent. I am aware that an investigation . <br /> of this statement may be made and that, If it is found to be a misstatement of fact, disciplinary action•_ <br /> including termination may be taken. I declare under penalty of perjury that the forgoing Is true an <br /> correct. <br /> Executed at , California, this , day of <br /> 19 <br /> Signed <br /> • <br /> • <br /> 218 <br /> FIRE -52 <br />