FMLA LEAVE REQUEST FORM — MARYLAND

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. Maryland-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:

☐ Serious Health Condition (Employee) — Employee's own serious health condition that renders the employee unable to perform the essential functions of the position.

☐ Serious Health Condition (Family Member) — To care for a spouse, child, parent, or other family member with a serious health condition.

☐ Birth of Child / Bonding — For the birth of a son or daughter and to bond with the newborn child within 12 months of birth.

☐ Adoption or Foster Care Placement — For the placement of a child for adoption or foster care and to bond with the newly placed child within 12 months of placement.

☐ Parental Leave (Maryland) — Unpaid leave for the birth, adoption, or foster placement of a child under the Maryland Parental Leave Act (employers with 15–49 employees).

☐ Qualifying Exigency (Military) — For any qualifying exigency arising from a family member's active military duty.

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

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 in 20 or more workweeks in the current or preceding calendar year.
• Employee eligibility: Must have worked for the employer for at least 12 months, have at least 1,250 hours of service, and work at a location with 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

If foreseeable, employee must provide at least 30 days' advance notice under federal FMLA. If not foreseeable, notice must be given as soon as practicable.

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. Maryland-Specific Considerations

Maryland Flexible Leave Act (Md. Code, Lab. & Empl. Art. § 3-1201 et seq.)

The Maryland Flexible Leave Act requires employers that provide paid leave to allow employees to use that leave for certain family purposes:

• Employer threshold: Employers with 15 or more employees.
• Requirement: Employees may use accrued paid leave (sick, vacation, PTO) to care for an immediate family member with an illness.
• Immediate family: Includes child, spouse, and parent.
• Limitation: Only applies if the employer already provides paid leave; does not create a new leave entitlement.

Maryland Parental Leave Act (Md. Code, Lab. & Empl. Art. § 3-802)

The Maryland Parental Leave Act fills a gap for employers too small for federal FMLA:

• Employer threshold: Employers with 15 to 49 employees.
• Leave duration: Up to 6 weeks of unpaid parental leave in a 12-month period.
• Qualifying events: Birth, adoption, or foster care placement of a child.
• Employee eligibility: Must have worked for the employer for at least 12 months and at least 1,250 hours in the preceding 12 months.
• Job protection: Employees must be restored to the same or equivalent position.

Maryland Family and Medical Leave Insurance — FAMLI (Title 8.3)

Maryland has enacted the Time to Care Act establishing the FAMLI program:

• Contribution start date: January 1, 2027 (delayed from earlier planned dates by HB 102, signed May 6, 2025).
• Benefits start date: January 3, 2028.
• Leave duration: Up to 12 weeks of paid leave in a 12-month application year.
• Qualifying reasons: Employee's own serious health condition; care for a family member with a serious health condition; bonding with a new child (including kinship care); military caregiver; qualifying exigency.
• Eligibility: Employees who have worked at least 680 hours in Maryland over the prior 12 months.
• Benefit amount: Up to 90% of weekly wages, maximum $1,000 per week.
• Contribution rates: 0.90% of gross wages for employers with 15+ employees (split between employer and employee); 0.45% for employers with fewer than 15 employees.
• Expanded family definition: Includes spouse, child, parent, grandparent, grandchild, sibling, and legal guardian.

FAMLI Program Status:

☐ FAMLI contributions are being collected (applicable after January 1, 2027).
☐ FAMLI benefits are available (applicable after January 3, 2028).
☐ FAMLI is not yet in effect — federal FMLA and other Maryland leave laws apply.

Maryland Healthy Working Families Act (Md. Code, Lab. & Empl. Art. § 3-1301 et seq.)

Maryland requires employers with 15 or more employees to provide earned sick and safe leave (up to 40 hours per year). This leave may be used concurrently with FMLA for qualifying reasons.

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 the Maryland Parental Leave Act, employees are entitled to be restored to the same or equivalent position with the same pay, benefits, and conditions of employment.

Under FAMLI (effective 2028), job protection will be provided for employees on approved paid leave.

☐ 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:

• FMLA leave is unpaid unless I elect or am required to substitute accrued paid leave.
• Maryland FAMLI paid benefits are not yet available (effective January 3, 2028).
• I must provide medical certification if requested by my employer.
• Failure to return from FMLA leave may result in the obligation to reimburse employer-paid health insurance premiums.
• Misrepresentation of facts may result in disciplinary action, up to and including termination.

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
• Md. Code, Lab. & Empl. Art. Title 8.3 — FAMLI Program
• Md. Code, Lab. & Empl. Art. § 3-802 — Maryland Parental Leave Act
• Md. Code, Lab. & Empl. Art. § 3-1201 — Maryland Flexible Leave Act
• Maryland FAMLI — Official Site

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