Form Hr/cs #13 - Request For Family And Medical Leave (Family And Medical Leave Act) - Dallas, Texas
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1REQUEST FOR FAMILY AND MEDICAL LEAVE
(Family and Medical Leave Act)
Department Name:
Department Contact Person:
Telephone Number:
Employee Name:
Employee’s Job Title:
Regular Work Schedule:
Reason for Request: (Select one)
Date of birth/adoption/placement:
Name of child:
Due to birth of my child, or placement
→
of a child with me for adoption or
___________________________
________________________
foster case:
Due to the serious health condition of
the employee (including pregnancy):
Check one:
Due to the serious health condition
→
[
] spouse; [ ] child; [ ] parent due to his/her serious health condition.
care
of
the
employee’s
family
member:
Check one:
Due to a serious injury or illness of an
→
[ ] spouse; [ ] son or daughter; [ ] parent; [ ] next of kin of a covered service
employee’s covered service member:
member with a serious injury or illness.
Check one:
Due to a qualifying exigency arising
→
[ ] spouse; [ ] son or daughter; [ ] parent is on active duty or called to active
out of the fact that my:
duty status in support of a contingency operation as a member of the National
Guard or Reserves.
Requested Leave Period:
Start Date (or expected start date):
Return Date (or expected return date):
Use this space to describe request for intermittent or reduced schedule FMLA leave:
Please check the statement below regarding the utilization of paid leave:
I do understand that I will be required to use my available paid sick, vacation, compensatory, holiday credit, and/or
personal day during my FMLA absence. This means that I will receive my paid leave and the leave will also be considered
protected FMLA leave and counted against my FMLA leave entitlement. After all paid leave has been exhausted, I will
move to an unpaid leave status for the remainder of my FMLA period.
Please check one of the options below to indicate whether or not you elect to continue or temporarily drop insurance
deductions:
I elect to continue insurance benefits and deductions for employee and dependents. I will remit timely payments for all such
benefits and coverages as specified by the Auditor’s Office.
I elect to temporarily drop insurance benefits and deductions for employee and dependents during the leave and
reinstate them upon returning to work.
I elect to temporarily drop insurance benefits and deductions for dependents only during the leave and reinstate them upon
returning to work. I will retain all of my insurance benefits and will remit timely payments as specified by the Auditor’s Office.
Note: If you elect to drop optional life, dependent life or long term care insurance while on FMLA, you have the option of re-electing
these insurance benefits. However, you will be required to go through medical underwriting for insurance benefit reinstatement. If
approved, the reinstatement will be effective the first of the month following underwriting approval. If you have FSA Dependent Care,
your contributions will automatically stop while you are on unpaid FMLA. Your FSA Dependent Care contributions will reinstate
upon return to work.
Employee Signature:
Date:
Received by Department: (Date): __________
Form HR/CS #13 (11/2009)
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