Request for FMLA Leave
Name: ______________________ |
Date: _____________ |
Position: ______________________ |
SSN: _____________ |
Address: ______________________ |
Does your spouse work for this company? ___________
Estimated Start Date: _________ Estimated Return Date: _________
Reason for the Leave: (please check one)
□ To care for my child after birth.
□ To care for a child placed in my home by adoption or foster care. Please indicate the date of placement: ___________ □ Anticipated □ Actual (check one)
□ To care for a family member who has a serious health condition. Please indicate relationship of family member: □ Spouse □ Child □ Parent (check one)
Name of family member: _______________________________________
(Note to employer: If your state allows leave to be taken intermittently, you may add an option to request this type of leave here.)
I understand that certification from a licensed medical care provider on behalf of myself or an immediate family member is needed for FMLA leave to be approved. I am also aware that the company is required to pay their usual contribution of my medical benefits while I am on leave, and that I am also required to pay my share. Failure to do so may result in discontinuation of my medical benefits due to lack of payment.
__________________________________ |
___________________ |
Employee Signature |
Date |
