FAMILY AND MEDICAL LEAVE ACT

LEAVE REQUEST & ACKNOWLEDGMENT AGREEMENT

(29 U.S.C. §§ 2601 et seq.)

[// GUIDANCE: This template is intended for U.S. employers subject to the federal Family and Medical Leave Act (“FMLA”). It is not a substitute for U.S. Department of Labor Forms WH-381, WH-382, WH-380-E/F, WH-384, WH-385, or WH-385-V, each of which remains mandatory where applicable. Attach or incorporate those forms as Exhibits, as indicated below.]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block
Exhibit A – Employee Leave Election Schedule
Exhibit B – Required FMLA Certifications (placeholders)

I. DOCUMENT HEADER

1. Parties
   1.1 Employer: [EMPLOYER LEGAL NAME], a [STATE] [corporation/LLC/other] (the “Employer”).
   1.2 Employee: [EMPLOYEE LEGAL NAME], [job title] (the “Employee”).

2. Effective Date (the “Effective Date”): [DATE].

3. Recitals
   A. The Employee asserts eligibility for leave under the Family and Medical Leave Act, 29 U.S.C. §§ 2601 et seq. (the “Act”).
   B. The Employer is a “covered employer” under the Act.
   C. The parties desire to formalize the Employee’s leave request and to allocate their respective rights and obligations in accordance with the Act and applicable regulations.

II. DEFINITIONS

(Definitions appear alphabetically; capitalized terms used but not defined herein have the meanings assigned in the Act or 29 C.F.R. Part 825.)

“Act” means the Family and Medical Leave Act of 1993, 29 U.S.C. §§ 2601–2654, and all implementing regulations.
“Applicable Law” means all federal, state, and local statutes, regulations, and ordinances governing the subject matter of this Agreement.
“Certification” means a completed and signed Department of Labor certification form (e.g., WH-380-E/F, WH-384, WH-385, or WH-385-V).
“Covered Service-Member Leave” has the meaning set forth in 29 U.S.C. § 2612(a)(3).
“FMLA Leave” means job-protected leave provided under the Act.
“Intermittent Leave” means non-continuous leave taken in separate blocks of time for a single qualifying reason.
“Leave Period” means the period identified in Section 3.1.
“Qualifying Exigency” has the meaning set forth in 29 U.S.C. § 2612(a)(1)(E).
“Serious Health Condition” has the meaning set forth in 29 U.S.C. § 2611(11).

III. OPERATIVE PROVISIONS

3.1 Leave Request
(a) Type of Leave Requested (check one):
☐ Birth/bonding with child
☐ Placement for adoption/foster care
☐ Employee’s Serious Health Condition
☐ Care for [family member] with Serious Health Condition
☐ Qualifying Exigency
☐ Covered Service-Member Leave
(b) Anticipated Leave Period: From [START DATE] through [END DATE].
(c) Leave Schedule: ☐ Continuous ☐ Intermittent ☐ Reduced Schedule
(d) Estimated Total Workdays/Hours Absent: [NUMBER].

3.2 Documentation & Certifications
(a) The Employee shall submit any required Certification within fifteen (15) calendar days of the Effective Date or as otherwise permitted by the Act.
(b) Failure to timely provide complete and sufficient Certification may result in denial, suspension, or termination of FMLA Leave in accordance with 29 C.F.R. § 825.305.

3.3 Substitution of Paid Leave
The Employee ☐ will ☐ will not substitute accrued paid [vacation/PTO/sick] leave during FMLA Leave. If substituted, the paid leave will run concurrently with FMLA Leave.

3.4 Maintenance of Benefits
(a) The Employer shall maintain group health plan coverage on the same terms as if the Employee had continued to work, pursuant to 29 U.S.C. § 2614(c).
(b) The Employee shall remit the employee-portion of premiums on or before [DATE/INTERVAL].

3.5 Return-to-Work
(a) The Employee shall provide a “fitness-for-duty” certification (where applicable) at least two (2) business days prior to returning from leave.
(b) The Employer shall restore the Employee to the same or an equivalent position as required by 29 U.S.C. § 2614(a), subject to the key-employee provisions (if applicable).

3.6 Conditions Precedent and Subsequent
(a) Employer’s obligations hereunder are conditioned on Employee’s continuing eligibility under the Act.
(b) Misrepresentation of material facts shall constitute an Event of Default under Section 6.1.

IV. REPRESENTATIONS & WARRANTIES

4.1 Employee Representations
(a) Employee meets the Act’s eligibility criteria (twelve months of service and 1,250 hours worked in the preceding twelve months).
(b) All information supplied in connection with the leave request is true, correct, and complete.
(c) Employee will notify Employer within two (2) business days of any facts that could modify eligibility or duration of leave.

4.2 Employer Representations
(a) Employer employs fifty (50) or more employees within seventy-five (75) miles of the Employee’s worksite.
(b) Employer will administer the Employee’s FMLA Leave in good faith compliance with the Act.

4.3 Survival
The representations and warranties herein shall survive the Leave Period and the Employee’s return to work.

V. COVENANTS & RESTRICTIONS

5.1 Employee Covenants
(a) Periodic Status Reports: Employee shall respond to Employer requests for status updates at reasonable intervals.
(b) Outside Employment: Employee shall refrain from gainful outside employment inconsistent with medical restrictions (if any) or with company policy.
(c) Premium Reimbursements: Employee shall reimburse Employer for group-health premiums paid during any period of unexcused, unauthorized absence.

5.2 Employer Covenants
(a) Non-Interference & Non-Retaliation: Employer shall not interfere with, restrain, or deny exercise of FMLA rights nor retaliate for their exercise.
(b) Records & Confidentiality: Employer shall maintain FMLA records separate from personnel files and treat medical information as confidential.

VI. DEFAULT & REMEDIES

6.1 Events of Default
(a) Failure to provide required Certification within the statutory period.
(b) Material misrepresentation by either party.
(c) Failure to remit employee-portion of premiums within thirty (30) days after written notice of delinquency.

6.2 Notice & Cure
Except for willful misrepresentation, the non-defaulting party shall provide written notice specifying the nature of the default and a seven-calendar-day cure period.

6.3 Employer Remedies
(a) Suspension or denial of FMLA Leave until cure.
(b) Recovery of employer-paid health-plan premiums as permitted by 29 C.F.R. § 825.213.

6.4 Employee Remedies
Employee retains all rights and remedies under 29 U.S.C. § 2617, including equitable relief (e.g., reinstatement), actual damages, interest, attorneys’ fees, and costs.

6.5 Attorneys’ Fees & Costs
In any action arising under or relating to this Agreement, the prevailing party shall be entitled to reasonable attorneys’ fees and costs as allowed by law.

VII. RISK ALLOCATION

7.1 Indemnification
(a) Employer shall indemnify and hold Employee harmless from any third-party claim arising solely from Employer’s failure to comply with its obligations under the Act, except to the extent such claim results from Employee’s breach.
(b) Employee shall indemnify and hold Employer harmless from any loss, cost, or expense arising from Employee’s fraudulent misrepresentation in the Certification or other leave documentation.

7.2 Limitation of Liability
Each party’s liability to the other under this Agreement shall be limited to actual, direct damages. Neither party shall be liable for consequential, incidental, or punitive damages.

7.3 Force Majeure
Neither party shall be liable for any delay or failure in performance caused by acts of God, war, terrorism, or any other event beyond that party’s reasonable control, provided that the affected party gives prompt notice and resumes performance as soon as practicable.

VIII. DISPUTE RESOLUTION

8.1 Governing Law
This Agreement and any dispute arising hereunder shall be governed by the Act and other applicable federal law, without regard to conflict-of-law principles.

8.2 Forum Selection
The parties consent to the exclusive jurisdiction of the United States District Court for the [FEDERAL DISTRICT] (or any appellate court therefrom) for any action arising out of or relating to this Agreement or the Act.

8.3 Limited Arbitration (Optional)
The parties may, by mutual written consent after any dispute arises, submit non-statutory claims (e.g., alleged policy violations) to binding arbitration under the Employment Arbitration Rules of the American Arbitration Association. Statutory claims under the Act remain subject to federal court jurisdiction.

8.4 Jury Trial
Nothing herein shall be construed as a waiver of either party’s constitutional right to a trial by jury with respect to any statutorily cognizable claim.

8.5 Injunctive Relief
Nothing in this Section restricts either party from seeking temporary or permanent injunctive relief, including but not limited to reinstatement.

IX. GENERAL PROVISIONS

9.1 Amendments & Waivers
No amendment or waiver shall be effective unless in a writing signed by both parties. A waiver on one occasion is not a waiver of any subsequent breach.

9.2 Assignment
Neither party may assign or delegate its rights or obligations hereunder without the other party’s prior written consent, except that Employer may assign to a successor by merger or asset acquisition.

9.3 Severability
If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force, and the invalid provision shall be reformed to the minimum extent required to give effect to the parties’ intent.

9.4 Entire Agreement
This document, together with Exhibits A and B, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written understandings.

9.5 Counterparts; Electronic Signatures
This Agreement may be executed in counterparts, each of which is deemed an original, and all of which together constitute one instrument. Signatures transmitted electronically (e.g., via PDF, DocuSign®, or similar platform) shall be deemed original.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the parties have executed this Family and Medical Leave Act Leave Request & Acknowledgment Agreement as of the Effective Date.

[// GUIDANCE: Add notarization or witness lines below only if required by your state or company policy.]

EXHIBIT A

EMPLOYEE LEAVE ELECTION SCHEDULE
[// GUIDANCE: HR should complete after discussing with the employee.]

EXHIBIT B

REQUIRED FMLA CERTIFICATIONS
1. WH-381 – Notice of Eligibility and Rights & Responsibilities (Employer-Prepared)
2. WH-382 – Designation Notice (Employer-Prepared)
3. [Select One or More Employee-Provided Forms:]
• WH-380-E – Employee’s Serious Health Condition
• WH-380-F – Family Member’s Serious Health Condition
• WH-384 – Qualifying Exigency
• WH-385 – Service-Member Caregiver (Current)
• WH-385-V – Service-Member Caregiver (Veteran)

[// GUIDANCE: Attach blank forms or reference internal HR portal where forms are made available.]