Election-Worker Service Leave Request and Appointing-Authority Certification Packet - Minnesota
ELECTION-JUDGE SERVICE LEAVE REQUEST AND APPOINTING-AUTHORITY CERTIFICATION
Minnesota — Minn. Stat. §§ 204B.195 and 204B.21, subd. 2
This packet is for an individual selected to serve as an election judge. It is not a request for time off to vote.
1. EMPLOYEE AND EMPLOYER
| Field | Entry |
|---|---|
| Employee | [________________________________] |
| Employer | [________________________________] |
| Position / worksite | [________________________________] |
| Normal schedule | [________________________________] |
| HR / supervisor | [________________________________] |
2. APPOINTMENT GATE
Election: [TYPE / DATE]
Precinct / assigned duties: [________________________________]
Appointing authority:
- ☐ Municipal governing body
- ☐ County board for unorganized territory or county-auditor duties
- ☐ Governing body designated by an election-combination agreement
Appointment date: [________________________________]
- ☐ Appointment made at least 25 days before the election.
- ☐ Appointment made within 25 days under an appointing-authority resolution determining that additional judges were required.
Appointing resolution, if applicable: [NUMBER / DATE]
3. TWENTY-DAY WRITTEN NOTICE
The employee gives written notice on [DATE] for service on [ELECTION DATE].
Days between notice and election service: [________]
- ☐ At least 20 days' written notice is provided.
- ☐ Fewer than 20 days remain; the employee requests voluntary employer approval and does not represent that § 204B.195's notice condition is satisfied without counsel review.
Notice method and recipient: [________________________________]
Employee signature: __________________________ Date: ______________
4. REQUIRED APPOINTING-AUTHORITY CERTIFICATION
The written leave request must be accompanied by a certification stating the hourly compensation and service hours.
I certify that [EMPLOYEE] was selected to serve as an election judge under Minn. Stat. § 204B.21, subd. 2.
| Required item | Certification |
|---|---|
| Election date | [________________________________] |
| Service start and end | [________________________________] |
| Total anticipated hours | [________] |
| Hourly compensation | $[________] |
| Appointing authority | [________________________________] |
Authorized signature: _________________________ Date: ______________
Printed name / title / contact: [________________________________]
5. EMPLOYER WORKSITE-CAP REVIEW
Section 204B.195 permits an employer to restrict simultaneous election-judge absences to no more than 20 percent of the total workforce at a single worksite.
| Worksite item | Number |
|---|---|
| Total workforce at this worksite | [________] |
| Maximum simultaneous election-judge absences at 20% | [________] |
| Previously approved election-judge absences | [________] |
| This request within cap | ☐ Yes ☐ No |
If the cap affects the request, record the neutral allocation method and any alternative assignment or schedule discussed:
[____________________________________________________________]
6. LEAVE AND WAGE TREATMENT
An employee who satisfies § 204B.195 may be absent to serve as an election judge without penalty. The employer may reduce salary or wages by the amount the appointing authority pays the election judge during the employee's work absence.
| Item | Entry |
|---|---|
| Scheduled work absence | [________________________________] |
| Employer wages for that period | $[________] |
| Appointing-authority compensation during that period | $[________] |
| Permitted wage reduction | $[________] |
| Other penalty imposed | None |
- ☐ Approved under § 204B.195
- ☐ Voluntarily approved despite a notice issue
- ☐ Worksite cap requires adjustment
- ☐ Counsel / labor-relations review required
Employer representative: _____________________ Date: ______________
Decision delivered to employee: [DATE / METHOD]
7. POST-SERVICE RECONCILIATION
Actual service hours: [________________________________]
Actual hourly and total election-judge compensation: [________________________________]
Actual overlap with scheduled work hours: [________________________________]
Payroll adjustment: [________________________________]
Employee and payroll acknowledgment: [________________________________]
OFFICIAL SOURCES VERIFIED
About this template
- Last updated
- August 10, 2026
- Citations checked
- August 10, 2026
- Jurisdiction
- Minnesota
- Category
- Employment & HR
Legal authority
- Minn. Stat. § 204B.195 (twenty-day written notice, appointing-authority certification, wage offset, and twenty-percent worksite cap)
- Minn. Stat. § 204B.21, subd. 2 (election-judge appointing authority and additional appointments within twenty-five days)
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on August 10, 2026.
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