Sample FMLA Leave Approval Letter

(Employers — note that your policy or state regulations may be different than the information provided in this sample.)


Employee Name:



(Hand deliver or send certified-mail return-receipt requested)


This letter is to inform you that your request for leave has been designated as Family and Medical Leave (FMLA) under the Family and Medical Leave Act of 1993. Your leave begins on MM-DD-YY and ends on MM-DD-YY. This time off will be charged against the twelve weeks of leave that you are entitled to receive in a rolling twelve-month period. The method for calculating the twelve-month period is explained in the written copy of the company's FMLA policy that you received on MM-DD-YY.

According to company policy, you are required to use the balance of your unpaid sick leave at the start of your leave. You currently have (number) hours on record. Your paycheck for this leave will be processed during the normal payroll cycle.

Once your paychecks are discontinued, you are required to pay for your health insurance premiums by the first of each month. Payments will be credited toward the insurance for the month in which they are paid. Premiums are payable by check or money order and may be sent to the company via U.S. mail to the attention of the accounting department. Please be sure to send a note with the payment or indicate on the reference line what the payment is for. The amount due by the first of each month is $264.76.

Your position will be held for you while you are on approved leave. If you do not return at the end of the twelve-week period, your position may no longer be available for you if you return at a later date.

Due to the nature of your leave, you will be required to present a return-to-work authorization from your physician before returning to work. This is for your protection to ensure that you are physically able to perform the essential duties of your job upon return.

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