University Of Maine System Request For Family Or Medical Leave Form printable pdf download

University of Maine System

Request for Family or Medical Leave

Name: __________________________________________

Date: __________________

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*

child

domestic partner’s child*

spouse

parent

sibling†

____ My own serious medical condition

____ Military Family Leave because of a qualifying exigency (12 week maximum)

Attach

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

form.

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.

University Of Maine System Request For Family Or Medical Leave Form

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