Election-Worker Service Leave Request and Appointing-Authority Certification Packet - Missouri

ELECTION-JUDGE SERVICE LEAVE REQUEST AND CERTIFICATION

Missouri — Mo. Rev. Stat. § 115.102

1. EMPLOYEE AND EMPLOYER

2. APPOINTMENT AND SERVICE

Election authority: [________________________________]

Election: [TYPE / DATE]

Election-judge assignment: [________________________________]

Appointment date: [________________________________]

Required election-day service period: [START / END]

3. SEVEN-DAY NOTICE

The employee notifies the employer on [DATE] of the election-day absence.

Days before the election: [________]

• ☐ At least seven days' notice is provided.
• ☐ Fewer than seven days remain; voluntary approval or counsel review is requested.

Notice method and recipient: [________________________________]

Employee signature: __________________________ Date: ______________

4. ELECTION-AUTHORITY CERTIFICATION

I certify that [EMPLOYEE] is appointed as an election judge and is required to serve on election day during the period stated below.

Required service: [DATE / START / END]

Compensation, if any: [________________________________]

Authorized signature: _________________________ Date: ______________

Printed name / title / contact: [________________________________]

5. LEAVE AND PAY TREATMENT

Section 115.102 permits absence for the period the election authority requires on election day and prohibits termination, discipline, threats, or adverse action based on election-judge service. The section does not state that the absence must be paid.

• ☐ Unpaid time
• ☐ Accrued paid leave voluntarily selected: [________________________________]
• ☐ Paid administrative or civic leave under another authority: [________________________________]
• ☐ Other: [________________________________]

Approved absence: [________________________________]

6. EMPLOYER RESPONSE

• ☐ Appointment confirmed
• ☐ Seven-day notice satisfied
• ☐ Required service period approved
• ☐ Pay treatment recorded
• ☐ Counsel / labor-relations review required

Employer representative: _____________________ Date: ______________

Decision delivered: [DATE / METHOD]

7. COMPLIANCE RECORD

An employee discharged in violation may bring the civil action described in § 115.102 within 90 days of discharge for lost wages, other resulting damages, reinstatement, and, if successful, reasonable attorney fees and costs.

Issue and response: [________________________________]

OFFICIAL SOURCE VERIFIED

• Missouri Revisor of Statutes — Mo. Rev. Stat. § 115.102