FMLA Request

FMLA Request

Texas Litter Control
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Leave Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employees in Texas may take up to 12 weeks of leave in a 12-month period for a serious health condition, bonding with a new child, or qualifying exigencies. I understand that I must notify the Operations Manager or Executive Director as soon as I am able to return or if I do not plan on returning to work. If I am unable to return by 12 weeks from the Leave Start Date as stated above, my employment will be terminated.
FMLA Leave Reason
Family Member Name

First NameLast Name
Select the relationship of the family member to you. The family member is your:
Spouse means a husband or wife as defined or recognized in the state where the individual was married, including in a common law marriage or same-sex marriage. The terms “child” and “parent” include in loco parentis relationships in which a person assumes the obligations of a parent to a child. An employee may take FMLA leave to care for an individual who assumed the obligations of a parent to the employee when the employee was a child. An employee may also take FMLA leave to care for a child for whom the employee has assumed the obligations of a parent with no legal or biological relationship.
Briefly describe the care you will provide to your family member: (Check all that apply.)

Other
Give your best estimate of the amount of leave needed to provide the care described:
Signature
Should be Empty: