FMLA Leave Request Form - Indiana
FMLA LEAVE REQUEST FORM — INDIANA
Before you use this: Give this completed request to the employer's designated leave contact. Provide medical certification through the employer's requested process rather than putting a diagnosis or medical records in this form. The employer's response should be given separately.
1. Employee and employer
| Field | Entry |
|---|---|
| Employee name | [________________________________] |
| Employee ID, if used | [________________________________] |
| Department and position | [________________________________] |
| Worksite | [________________________________] |
| Phone or email for leave contact | [________________________________] |
| Employer name | [________________________________] |
| Supervisor or leave contact | [________________________________] |
2. Reason for requested leave
Check every reason that applies. Federal FMLA and Indiana military family leave have different eligibility rules; this form does not determine which applies.
☐ My own serious health condition affects my ability to perform my job.
☐ I need to care for my spouse, child, or parent with a serious health condition.
☐ Birth of my child and care for the child.
☐ Placement of a child with me for adoption or foster care.
☐ A qualifying exigency related to my spouse's, child's, or parent's covered active duty or impending call or order to covered active duty.
☐ Care for a covered servicemember with a serious injury or illness. My relationship to the servicemember: [________________________________].
☐ Indiana military family leave related to a qualifying active-duty order for my spouse, parent, grandparent, child, or sibling. Relationship: [________________________________].
Brief description of the need for leave, without diagnosis or medical details: [____________________________________________________________].
3. Dates and schedule requested
| Field | Entry |
|---|---|
| First day of leave requested | [__/__/____] |
| Expected last day of leave | [__/__/____] |
| Expected date of return, if known | [__/__/____] |
| Date I first learned leave would be needed | [__/__/____] |
| Date and method of any earlier notice to employer | [________________________________] |
| For Indiana military family leave, date active-duty orders were issued, if known | [__/__/____] |
☐ Continuous leave. ☐ Intermittent leave. ☐ Reduced schedule.
Expected frequency, duration, or reduced hours, if known: [____________________________________________________________].
If the requested dates may change, explain what is uncertain: [____________________________________________________________].
For Indiana military family leave, the expected dates relate to: ☐ the 30 days before the orders take effect; ☐ while the service member is on leave during the active-duty orders; ☐ the 30 days after the orders terminate. Active-duty orders: ☐ attached ☐ requested and will be provided when available.
For Indiana military family leave, give the employer written notice of the leave start date at least 30 days before leave begins, unless the active-duty orders were issued less than 30 days before that date. Include a copy of the orders if available.
4. Paid leave and supporting information
☐ Please tell me what accrued paid leave may be used with this request. ☐ I request use of available paid leave under applicable policy. Leave type and dates requested: [________________________________].
☐ I can provide the employer's requested certification or other supporting information through its designated process. ☐ I have requested that process or form. Date: [__/__/____].
Preferred contact method during leave, if needed: [________________________________].
5. Employee signature
I request the leave described above and will update the employer if the requested dates or schedule change. The information I supplied is accurate to the best of my knowledge.
Employee signature: [________________________________] Date: [__/__/____]
6. Employer receipt record
This section records receipt only. The employer should make and communicate its coverage, eligibility, designation, certification, pay, benefits, and restoration decisions separately under applicable law and policy. A key-employee designation under 29 C.F.R. § 825.217 does not alone establish grounds to deny restoration; § 825.218(a) addresses the required economic-injury determination.
| Field | Entry |
|---|---|
| Date received | [__/__/____] |
| Received by | [________________________________] |
| Separate notice or form sent to employee, if any | [________________________________] |
| Date sent | [__/__/____] |
Sources and references
About this template
- Last updated
- October 21, 2026
- Citations checked
- October 21, 2026
- Jurisdiction
- Indiana
- Category
- Employment & HR
Legal authority
- 29 U.S.C. § 2611
- 29 U.S.C. § 2612
- 29 U.S.C. § 2613
- 29 U.S.C. § 2614
- 29 C.F.R. § 825.217
- 29 C.F.R. § 825.218
- Ind. Code § 22-2-13-1
- Ind. Code § 22-2-13-11
- Ind. Code § 22-2-13-12
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 October 21, 2026.
29 U.S.C. § 2611(2)(A) (checked October 18, 2026): "The term “eligible employee” means an employee who has been employed— (i) for at least 12 months by the employer with respect to whom leave is requested under section 2612 of this title; and (ii) for at least 1,250 hours of service with such employer during the previous 12-month period."
29 U.S.C. § 2612(a)(1) (checked October 18, 2026): "an eligible employee shall be entitled to a total of 12 workweeks of leave during any 12-month period for one or more of the following:"
29 U.S.C. § 2613(a) (checked October 18, 2026): "An employer may require that a request for leave under subparagraph (C) or (D) of paragraph (1) or paragraph (3) of section 2612(a) of this title be supported by a certification issued by the health care provider"
29 U.S.C. § 2614(a)(1) (checked October 18, 2026): "any eligible employee who takes leave under section 2612 of this title for the intended purpose of the leave shall be entitled, on return from such leave— (A) to be restored by the employer to the position of employment held by the employee when the leave commenced; or (B) to be restored to an equivalent position"
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