Application For Family And Medical Leave Form printable pdf download

APPLICATION FOR FAMILY MEDICAL LEAVE

Employee Name _________________________________________Personnel Number _______________

Agency Name ______________________________________________________________________

Agency Address _____________________________________________________________________

Regular Hours worked Per Week _______________________________________________________

Home Address _____________________________________________________________________

Home Phone (_____) __________________

Work Phone (_____)_________________

PURPOSE of Family and Medical Leave (for example: birth or placement of a child, own serious health condition, family member’s

serious health condition, leave for qualifying family member’s military leave): ________________________________________

______________________________________________________________________________________________________

_______________________________________________________________________________________________________.

Please check one of the following:

____

I request to presently utilize family and medical leave concurrently with my accumulated paid leave pursuant to 101 KAR

2:102 Section 3(6)(b) and/or 101 KAR 3:015 Section 3(6)(b).

____

I do not wish to utilize family and medical leave concurrently with my accumulated paid leave pursuant to 101 KAR 2:102

Section 3(6)(b) and/or 101 KAR 3:015 Section 3(6)(b). Therefore, I will not be entitled to the protections of the federal

Family and Medical Leave Act until I have exhausted all of my accrued paid leave.

____

I do not wish to utilize family and medical leave concurrently with my accumulated paid leave pursuant to 101 KAR 2:102

Section 3(6)(b) and/or 101 KAR 3:015 Section 3(6)(b). However, in accordance with 101 KAR 2:102 Section 3(6)(a) and/or

101 KAR 3:015 Section 3(6)(a), I request to reserve ________ (not to exceed 10) days of my accumulated sick leave prior

to my commencement of family and medical leave. I will not be entitled to the protections of the federal Family and

Medical Leave Act until I have exhausted my accrued paid leave in accordance with this election.

Attach supporting documentation, if required.

Anticipated duration of leave from _______________ to _______________ for a total of _______________ work days. In requesting

family leave, I certify that all information on this application is true and that I will abide by the regulations governing family leave.

_________________________________________________ ___

__________________________________

Employee Signature

Date

FOR AGENCY USE ONLY:

Family and Medical Leave Approved _________ for dates ____________________ to _____________________

Family and Medical Leave Denied ______________ Family and Medical Leave Balance as of this date ___________

Date Family and Medical Leave Designation Letter sent ___________________

___________________________________________________

__________________________________

Signature of Appointing Authority or Designee

Date

Revised January 2015

Application For Family And Medical Leave Form