FORMAL REQUEST FOR MATERNITY LEAVE
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Employee ID No.: ________
Date: ________
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RE: Formal Request for Maternity Leave
Dear ________:
§1. Purpose of This Letter. This letter serves as my formal written request for maternity leave in connection with the birth of my child. My anticipated due date, as confirmed by my health care provider, is ________. I am submitting this request in accordance with applicable federal and state law and the leave policies of ________ (the “Company”).
§2. Statutory Basis for Request. To the extent I am eligible, I request that this leave be designated as job-protected leave under the federal Family and Medical Leave Act of 1993, 29 U.S.C. §§ 2601 et seq. (the “FMLA”), and its implementing regulations at 29 C.F.R. Part 825, as well as under any applicable state family and medical leave, pregnancy disability, or paid family leave statute, including ________. I further request reasonable accommodation, if and to the extent applicable, under the Pregnant Workers Fairness Act, 42 U.S.C. §§ 2000gg et seq., and the Pregnancy Discrimination Act, 42 U.S.C. § 2000e(k). Nothing in this letter shall be construed as a waiver of any right or protection afforded to me under federal, state, or local law.
§3. Requested Duration of Leave. I am requesting maternity leave for the following period: ________. I respectfully request that my leave commence on ________ and conclude on ________, with my anticipated return-to-work date being ________. I understand that actual dates may be adjusted in accordance with my health care provider’s certification and the Company’s policies, and I will provide timely notice of any necessary changes.
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§5. Notice and Documentation. I am providing this notice as far in advance as practicable, consistent with 29 C.F.R. § 825.302. I am prepared to furnish any medical certification or supporting documentation reasonably required to substantiate this request, including a certification from my health care provider, ________. Kindly identify any specific forms the Company requires and the deadline for their submission.
§6. Transition of Duties. Prior to the commencement of my leave, I will work diligently to ensure that my work is properly documented and assigned to appropriate co-workers or subordinates. I welcome the Company’s direction on transition arrangements and will cooperate fully to minimize any disruption to operations.
§7. Contact During Leave. I respectfully request that no routine work-related calls, emails, or other obligations be directed to me during my leave. I intend to remain reachable solely for genuine emergency matters at my personal contact information set forth above.
§8. Return to Work. Upon the conclusion of my leave, I am committed to resuming my full duties and responsibilities and to being restored to the same or an equivalent position consistent with 29 U.S.C. § 2614(a). I will coordinate with you to ensure a seamless transition back into my role and am available to discuss any arrangements necessary to facilitate this process.
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I am submitting a copy of this request to the appropriate human resources department of the Company. Thank you for your attention to this matter. I look forward to working with you to ensure a smooth transition for my leave and my eventual return to work.
Sincerely,
______________________________
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Date: ________
cc: Human Resources Department, ________