APPLICATION FOR LEAVE OF ABSENCE UNDER THE FMLA 

I hereby make request for leave of absence under the Family and Medical Leave Act (FMLA) of 1993 for the following reason(s):

[Note: provide space on the form for the employee to list the reason(s) for the leave.]

I understand I may [optional:BE REQUIRED TO] use my accrued sick [optional:VACATION] days as part of my leave of absence under the FMLA. After I have exhausted my sick [optional:VACATION] days, I understand that the remainder of the leave will be without pay. 

I also understand that I am required to pay for my portion of the health insurance premiums and if I fail to pay these premiums, that my health insurance coverage will either cease immediately, or at the Company s option it will pay my share and the Company will recover any such monies paid on my behalf. Further, if I fail to return to work after the expiration of the leave, I am expected to reimburse the Company for its share of the health insurance premiums, except under certain limited circumstances.

My leave of absence will begin on ___ /___ /___ and end on ___ /___ /___ .

Employee Name (please print) ____________________________________

Social Security Number _________________________________________

Home Phone (include area code) __________________ Weekly or Monthly

Employee Signature ______________________________________ Date__________________

Manager s Signature ______________________________________ Date__________________

NOTE: If you wish to extend your unpaid leave of absence beyond the twelve weeks provided under the FMLA, you may apply for another leave of absence now in addition to your FMLA leave or prior to the expiration of your FMLA 

Reprinted with permission. © CCH