Mta Family And Medical Leave Act Application Form (Page 2 of 2) in pdf

Mta Family And Medical Leave Act Application Form Page 2

Family and Medical Leave Act Application Form

HR-BEN-028

Section 4 – Request for Leave

Leave beginning on

and leave ending on

Total number of work days

or total number of work weeks

Section 5 – Type of Leave Requested

a) State the type of leave you are requesting:

Intermittent

Reduced Schedule

Continuous

(Intermittent Leave is separate blocks of time due to a single qualifying reason. A reduced schedule leave is a leave schedule that reduces

your usual number of working hours per workweek or hours per work day, and a continuous leave is taken in consecutive blocks of time.)

b) If Intermittent, or reduced schedule leave, state the schedule you are requesting:

Section 6 - Authorization

I do hereby certify that to the best of my knowledge the above information is true and correct.

I understand that fraudulently requesting, obtaining and/ or misusing this leave will be cause for disciplinary action, up to and including dismissal

from employment.

Employee Signature

Date

___________/__________/____________

For Agency Human Resources Use Only (check one):

Meets Eligibility Requirements:

Does Not Meet Eligibility Requirements:

Signature

Date

Print Name

_______/_______/_20_____

Business Service Center

Last Revised: 12/06/2016

Creation Date: 04/01/2012

Mta Family And Medical Leave Act Application Form Page 2