[Instruction: Insert employee letterhead here.]
___ [Instruction: Insert date.]
_____ [Instruction: Insert employee name.]
_____ [Instruction: Insert address.]
_____ [Instruction: Insert city, state, zip code.]
Re: Employee Request for FMLA leave
Dear ____________________: [Instruction: Insert applicable company contact name.]
I am hereby requesting leave pursuant to my rights under the Family Medical Leave Act
(FMLA). I am requesting ____ [Instruction: Insert type of leave, for instance, full-time, part-
time or intermittent leave.] FMLA leave for the following reason: _____ [Instruction: Insert
FMLA permitted reason. I anticipate this leave will begin ____ and end approximately _____.
[Instruction: Insert anticipated leave commencement and end dates. Where practicable,
this leave request should be submitted 30 days prior to requested leave commencement
date.]
[Optional language: If permitted, I request to all available paid time off as substitute paid
leave time. If my requested leave is approved, I will make all necessary arrangements to
pay my applicable share of health insurance premiums while on unpaid leave.]
Sincerely,
[Instruction: Insert employee signature.]
© Copyright 2012 Docstoc Inc. 1
Docstoc Description: This attorney drafted letter sets forth the initial employee written request
pursuant to the provisions of the Family Medical Leave Act (FMLA). Where possible, same
should be sent 30 days before leave is requested to begin. This document does not set forth
specific language to be used where leave is requested due to qualifying exigency for military
service.
© Copyright 2012 Docstoc Inc. 2