Leave of Absence Request Letter - Template, Sample Form

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Telephone: ________
Email: ________
Employee ID No.: ________

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________, ________
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Re: Formal Request for Leave of Absence

Dear ________,

§ 1. Purpose of Request. I am writing to formally request a leave of absence from my position as ________ with ________ (the “Company”), to commence on ________ and to conclude on ________, with my anticipated return to active duty on ________. The total duration of the requested leave is ________.

§ 2. Reason for Leave. The purpose of this leave of absence is the following:

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§ 3. Statutory and Policy Basis. To the extent applicable, I respectfully submit this request pursuant to (i) the Family and Medical Leave Act of 1993, 29 U.S.C. §§ 2601 et seq. (“FMLA”), and its implementing regulations at 29 C.F.R. Part 825; (ii) any applicable state or local leave statutes; and (iii) the Company’s established leave policies as set forth in its employee handbook. The category of leave requested is:

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I acknowledge that nothing in this letter shall be construed as a waiver of any rights afforded to me under the FMLA, the Americans with Disabilities Act (42 U.S.C. §§ 12101 et seq.), the Uniformed Services Employment and Reemployment Rights Act (38 U.S.C. §§ 4301 et seq.), or any other applicable federal, state, or local law.

§ 4. Use of Accrued and Statutory Leave. During my absence, I intend to apply ________ of accrued paid leave time available to me under Company policy. I further request that ________ of FMLA leave be designated during this period, where applicable. To the extent any portion of the leave is unpaid, I understand and agree that it will be administered in accordance with the Company’s policies and applicable law.

§ 5. Continuation of Benefits. I understand that, in accordance with 29 C.F.R. § 825.209 and applicable Company policy, my group health insurance coverage will be maintained on the same terms during any qualifying FMLA leave, and I agree to remit any required employee contributions during the leave period in the manner directed by the Company.

§ 6. Supporting Documentation. I have enclosed the documentation necessary to support this request, including the following:

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I am committed to providing any additional certification, medical documentation, or information that may reasonably be required to process this request promptly and in compliance with applicable law and Company policy.

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Thank you for considering my request. I value my role at ________ and look forward to resuming my duties promptly upon the conclusion of my leave.

Respectfully submitted,

_______________________________
________, ________
Date: ________

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FOR COMPANY USE ONLY — ACTION ON REQUEST

The above request for leave of absence is hereby: ________ (Approved / Approved as Modified / Denied).

Approved leave commencement date: ________   Approved return date: ________

FMLA designation (if applicable): ________

Comments / Conditions: ________

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________, ________
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Date: ________