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Maternity Leave Request - Template, Sample Form Pro · PH-law

✓ Valid in Philippines · drafted to comply with local law

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Maternity Leave Request - Template, Sample Form
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Re: Application for Maternity Leave under Republic Act No. 11210

Dear ________:

I respectfully write to formally apply for maternity leave by reason of my pregnancy, in accordance with Republic Act No. 11210, otherwise known as the “105-Day Expanded Maternity Leave Law,” its Implementing Rules and Regulations, and the pertinent provisions of the Labor Code of the Philippines and Social Security Act of 2018 (Republic Act No. 11199).

§ 1. Employment Details. I am presently employed with ________ as ________, having commenced employment on ________, with employee identification number ________.

§ 2. Intended Period of Leave. I intend for my maternity leave to commence on ________ and to end on ________, covering a total of ________ days. The estimated date of my delivery, as certified by my attending physician, is ________.

§ 4. Allocation of Leave Credits. I hereby manifest my intention ________ to allocate up to seven (7) days of my maternity leave benefit to the child’s father or an alternate caregiver, as permitted under Section 6 of Republic Act No. 11210. The details of the allocation, if any, are set forth in the accompanying allocation form.

§ 5. Eligibility for SSS Maternity Benefit. I respectfully represent that I have complied with the qualifying conditions under Republic Act No. 11199, having remitted at least three (3) monthly contributions within the twelve (12)-month period immediately preceding the semester of my expected date of delivery, and that I have duly notified my employer and the Social Security System of my pregnancy in accordance with the prescribed rules.

§ 6. Supporting Documents. Attached herewith for your reference are the following: (a) a medical certificate issued by my attending physician indicating the fact and details of my pregnancy and the estimated date of delivery; (b) the duly accomplished SSS Maternity Notification; and (c) such other documents as may be required, namely ________.

§ 8. Contact and Return to Work. You may reach me at ________ or at ________. Should I be unreachable during my leave, I will be glad to attend to any matters requiring my attention upon my return to work, which I anticipate to be on or about ________.

I trust this application merits your favorable consideration. Thank you.

Very truly yours,



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Received by:


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Date Received: ________

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