NOTE: This form is available as a printer-friendly, PDF.
Employee Request for Family and Medical Leave (FMLA)
Date: _____________________________________
TO: (name of supervisor) _______________________________________________________________________
FROM: (name of employee) _____________________________________________________________________
Department/Division _______________________________________________________________________
SUBJECT: Request for Family and Medical Leave (FMLA Leave)
I have worked for Montgomery County for a total of at least 12 months:
_____Yes _____No _____Unsure
I have worked for Montgomery County for at least 1040 hours, not including hours of paid leave, during the past 12 months:
_____Yes _____No _____Unsure
_____I need to take FMLA leave because of:
_____the birth of a child, or the placement of a child with me for adoption or foster care;
_____a serious health condition that makes me unable to perform the essential functions of my job;
_____a serious health condition affecting my
_____spouse
_____domestic partner
_____minor child
_____adult child incapable of self-care
_____parent;
_____to handle an exigency directly related to active duty status or a call to active duty of my
_____spouse
_____domestic partner
_____son or daughter
_____parent; or
_____to care for a servicemember with a serious injury or illness incurred in the line of duty while on active duty who is my
_____spouse
_____domestic partner
_____son or daughter
_____parent
_____next of kin
_____I need this leave to begin on (date) _______________________________ and expect it to continue until (date)_________________________________ and want to take this leave using:
_____accrued annual leave
_____accrued sick leave or family sick leave
_____accrued personal leave
_____leave without pay
_____some combination of the above
_____I need to take this FMLA leave on an intermittent or as needed bases.