FMLA LEAVE REQUEST FORM — MASSACHUSETTS

Table of Contents

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Leave Schedule and Dates
6. Intermittent or Reduced Schedule Leave
7. Medical Certification
8. Massachusetts-Specific Considerations
9. Job Restoration Rights
10. Benefits During Leave
11. Employee Certification and Signature
12. Employer Response
13. Sources and References

1. Employee Information

2. Employer Information

3. Type of Leave Requested

Please check the applicable reason for leave:

☐ Medical Leave (Employee) — Employee's own serious health condition, including pregnancy, childbirth, or related conditions (up to 20 weeks under MA PFML).

☐ Family Leave — Care for Family Member — To care for a family member with a serious health condition (up to 12 weeks under MA PFML).

☐ Family Leave — Bonding with New Child — For the birth, adoption, or foster placement of a child and bonding within 12 months (up to 12 weeks under MA PFML).

☐ Family Leave — Military Qualifying Exigency — For any qualifying exigency arising from a family member's active military duty (up to 12 weeks under MA PFML).

☐ Military Caregiver Leave — To care for a covered servicemember with a serious injury or illness (up to 26 weeks under federal FMLA).

☐ Safe Leave — To address the effects of domestic violence against the employee (under M.G.L. c.149 § 52E).

4. Federal FMLA Overview

Under the federal Family and Medical Leave Act (29 U.S.C. § 2601 et seq.):

• Eligible employees may take up to 12 workweeks of unpaid, job-protected leave in a 12-month period (or 26 weeks for military caregiver leave).
• Employer coverage: Private employers with 50 or more employees.
• Employee eligibility: 12 months of service, 1,250 hours worked, and 50+ employees within 75 miles.
• Leave is unpaid, but employees may elect or the employer may require the substitution of accrued paid leave.

5. Leave Schedule and Dates

Federal FMLA: 30 days' advance notice if foreseeable.
Massachusetts PFML: 30 days' advance notice if foreseeable; notice as soon as practicable if not foreseeable.

6. Intermittent or Reduced Schedule Leave

☐ I am requesting intermittent leave (leave taken in separate blocks of time).
☐ I am requesting a reduced work schedule (reducing the usual number of hours per workweek or workday).

If applicable, provide details:

7. Medical Certification

☐ Medical certification is attached.
☐ Medical certification will be provided by: [__/__/____]

Certifying Health Care Provider:

8. Massachusetts-Specific Considerations

Massachusetts Paid Family and Medical Leave (M.G.L. c.175M)

Massachusetts operates a comprehensive PFML program, effective January 1, 2021:

Leave Entitlements:
- Medical Leave (own condition): Up to 20 weeks per benefit year.
- Family Leave (caregiving, bonding, military): Up to 12 weeks per benefit year.
- Combined maximum: Up to 26 weeks per benefit year when an employee qualifies for both medical and family leave.

2026 Benefit Amounts:
- Maximum weekly benefit: $1,230.39 (2026).
- Benefit calculation: 80% of wages up to 50% of the state average weekly wage, plus 50% of wages above that threshold, up to the maximum.

2026 Contribution Rates:
- Total contribution rate: 0.88% of eligible wages (for employers with 25+ covered individuals).
- Employer share: 0.42% (60% of the medical leave contribution).
- Employee share: 0.46% (0.28% medical leave + 0.18% family leave).
- Employers with fewer than 25 covered individuals are not required to pay the employer share.

Eligibility:
- Employees must have earned at least $6,300 in the last four completed calendar quarters (or alternate base period) and meet monetary eligibility requirements.
- Coverage applies to nearly all W-2 employees and eligible 1099-MISC workers.

Expanded Family Definition:
Under MA PFML, "family member" includes spouse, domestic partner, child (any age), parent, parent of spouse/domestic partner, grandchild, grandparent, and sibling.

Massachusetts Parental Leave Act (M.G.L. c.149 § 105D)

The Massachusetts Parental Leave Act provides additional protections:

• Employer threshold: Employers with six (6) or more employees.
• Leave duration: 8 weeks of unpaid parental leave for the birth or adoption of a child under age 18 (or under age 23 if the child has a mental or physical disability).
• Eligibility: Employees who have completed their probationary period or three consecutive months of full-time employment.
• Job protection: Employees must be restored to the same or similar position.

MA PFML Application

Employee intends to apply for PFML benefits:

☐ Yes — through the state DFML system.
☐ Yes — through employer's approved private plan.
☐ No — employee will use accrued paid leave or take unpaid leave only.

Private Plan Information (if applicable):

Coordination of Leave Programs

Additional Employer Policies:

☐ Employer offers supplemental paid leave: [________________________________]
☐ Employer does not offer supplemental paid leave beyond statutory requirements.

9. Job Restoration Rights

Under federal FMLA, eligible employees are entitled to restoration to the same or equivalent position.

Under MA PFML (M.G.L. c.175M), employees are entitled to be restored to the same or an equivalent position upon return from approved paid leave.

Under the Massachusetts Parental Leave Act, employees are entitled to restoration to the same or similar position.

☐ Employee has been identified as a key employee under 29 C.F.R. § 825.218.

10. Benefits During Leave

Type and amount of accrued paid leave available:

11. Employee Certification and Signature

I certify that the information provided in this request is true and complete to the best of my knowledge. I understand that:

• I may be eligible for Massachusetts PFML benefits providing partial wage replacement during qualifying leave.
• Federal FMLA leave is unpaid but may run concurrently with MA PFML.
• I must provide medical certification if requested.
• I must file a PFML application with the DFML or my employer's private plan administrator to receive benefits.
• Misrepresentation of facts may result in disciplinary action and/or denial of benefits.

Employee Signature: [________________________________]
Date: [__/__/____]

12. Employer Response

HR Representative Signature: [________________________________]
Title: [________________________________]
Date: [__/__/____]

13. Sources and References

• U.S. Department of Labor — FMLA Fact Sheet #28
• 29 U.S.C. § 2601 et seq. — Family and Medical Leave Act
• M.G.L. c.175M — Massachusetts Paid Family and Medical Leave
• M.G.L. c.149 § 105D — Massachusetts Parental Leave Act
• Massachusetts DFML — PFML Overview and Benefits
• 458 C.M.R. 2.00 — DFML Regulations

This document is a template only and does not constitute legal advice. Legal review is strongly recommended before implementation. Massachusetts employers should ensure compliance with all applicable federal and state employment laws, including coordination of federal FMLA, MA PFML, and the Parental Leave Act.