University of Maine System
Request for Family or Medical Leave
Department: __________________ Contact number: H:________________ C:________________
Contact email: ___________________________________________________
I am requesting a Family and Medical Leave for the period starting _________and ending_______.
I am requesting leave in the form of intermittent leave or reduced hours as follows (specify starting and
ending dates and the hours to be taken as leave):
This leave is requested for:
____Birth of a child
____Caring for a newborn child
____Caring for a child placed for adoption or foster care
____Caring for a family member with a serious medical condition:
(select as appropriate)
domestic partner’s child*
____ My own serious medical condition
____ Military Family Leave because of a qualifying exigency (12 week maximum)
Certification of Qualifying Exigency for Military Leave form
____ Military Family Leave to care for a covered servicemember with a serious injury or
illness (26 week maximum) Attach
Certification for Serious Injury or Illness of Covered
Servicemember for Military Family Leave
Anticipated leave balances (in hours) at beginning of leave:
Annual leave: _____
Disability leave: _____
Compensatory time: _____
I will use accrued annual leave, disability leave (as allowed by University policy) and compensatory
time for the period starting ______________and ending _________________.
I will take leave without pay for the period starting _____________ and ending ___________.
I do ____ do not _____ wish to retain 40 hours of annual leave (applicable if balance of 40 or more
hours of annual leave has been accrued).
If leave is for the care of a newborn child or a child placed for adoption or foster care, enter the date (or
expected date) of birth or placement: _____________________________________
Leave to provide care for a domestic partner or the domestic partner’s child is covered under state law and requires
completion of the Affidavit of Domestic Partnership (available at ).
An employee is eligible for family medical leave to care for a sibling if: a) the employee and sibling are jointly
responsible for each other’s common welfare as evidenced by joint living arrangements and joint financial arrangements, or
b) the sibling is a member of the Armed Forces, including the National Guard and Reserves, and incurs a serious health
condition or dies while on active duty.