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Minnesota ied _________________ _________________ __________________________ Signature of Employer ________________________ Date y benefits will continue during my leave and that I will arrange to pay my share of any benefit premiums. __________________________ Signature of Employee ________________________ Date Approved Den agree to return to work on ____________________ . If any circumstances change and I am unable to return to work on that date, I agree to inform my employer immediately in writing. I understand that m foster care Explain: _______________________________________________ ______________________________________________________ ___ ___ Dates of requested leave: From: ____________ To:_____________ Ius health condition of child, spouse, or parent Explain: _______________________________________________ ______________________________________________________ Care for child after birth, adoption, orested Leave ___ Serious health condition that makes you unable to perform your job Explain: _______________________________________________ ______________________________________________________ Serio other time off from your scheduled __ ___ work? If yes, explain: _____________________ _______________________________________ Yes ___ No ___ ___ ___ ___ ___ ___ ___ ___ ___ Reasons for Requ_________________ _______________________________________ 4. Have you taken any intermittent leave? If yes, explain: __________________________ ______________________________________ 5. Have you takenpast 12 months, have you worked at least 1,250 hours? 3. Have you previously received medical or family leave? If yes, explain: Dates of previous leave: From ______ to ______ Purpose of leave: _______uch denial or postponement would be permitted under federal or state law. Eligibility 1. Have you worked for the company for a total of 12 months or more (whether or not consecutively)? 2. During the s form 30 (thirty) days in advance is not possible, submit the request as early as possible. The employer reserves the right to deny or postpone leave for failure to give appropriate notice whenever sb-protected leave for certain family and medical reasons. Please submit this request form to your supervisor at leave 30 (thirty) days before the leave is to begin, if possible. When submission of thi____________ Department _________________ Date hired __________________ Under the Federal Family and Medical Leave Act (FMLA), eligible employees are entitled to up to 12 (twelve) weeks of unpaid, jo all serious legal matters. Family and Medical Leave Form Date of request _______________ Employee name ___________________________________________ Social Security number _________ Job title _______on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consulted for, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused and . In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incidentaled "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own riskls. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are providafter birth, adoption, or foster care requires full-time attention of the employee (whether employee is father or mother) Disclaimer No Attorney-Client relationship is created by use of these materiacondition that makes him or her unable to perform his or her job, OR Have a child, spouse, or parent with a serious health condition that requires the employee's full-time care, OR Have a child which ditions: · · · · · Have worked for the company for a total of 12 months (does not need to be consecutive) Have worked for the company at least 1,250 hours in the last 12 months Have a serious health t which requires that eligible employees be entitled to up to 12 weeks of unpaid and job-protected leave for certain family and medical reasons. To be eligible, an employee must meet the following conInformation Family and Medical Leave Form Provided under agreement with copyright holder, © Nova Publishing Company 2004 This form is to be used to comply with the Federal Family and Medical Leave Ac Minnesota