FMLA Leave Request Form

provide explanatory notes.
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FMLA LEAVE REQUEST FORM — MAINE

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. Maine-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, domestic partner, child, or parent with a serious health condition.

☐ Birth of Child / Bonding — For the birth of a child and to bond with the newborn child.

☐ Adoption or Foster Care Placement — For the placement of a child age 16 or under for adoption or foster care.

☐ Death of Family Member — For the death of a spouse, domestic partner, parent, sibling, child, or stepchild (Maine state law).

☐ Organ Donation — For the donation of an organ for a human organ transplant (Maine state law).

☐ Safe Leave — To address the effects of domestic violence, sexual assault, or stalking against the employee or the employee's family member (Maine PFML).

☐ 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

Federal FMLA: If foreseeable, employee must provide at least 30 days' advance notice.
Maine State Leave: If foreseeable, employee must provide at least 30 days' advance notice where 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. Maine-Specific Considerations

Maine Family Medical Leave Requirements (26 M.R.S.A. § 843–848)

Maine's unpaid family medical leave law provides protections that differ from and in some respects exceed federal FMLA:

• Employer threshold: Employers with 15 or more employees at one location (and 25 or more total employees statewide).
• Employee eligibility: Must have worked for the employer for 12 consecutive months.
• Leave duration: Up to 10 consecutive workweeks of unpaid leave in any two-year period.
• Qualifying reasons: Serious health condition of the employee or family member; birth of a child; adoption or foster placement of a child age 16 or under; organ donation; death of a family member.
• Expanded family definition: Includes domestic partners, siblings, and stepchildren — broader than federal FMLA.

Maine Paid Family and Medical Leave (26 M.R.S.A. § 850-A–850-R)

Effective May 1, 2026, Maine's PFML program provides paid leave benefits:

• Coverage: Nearly all employees in Maine, regardless of employer size.
• Leave duration: Up to 12 weeks of paid leave per benefit year.
• Qualifying reasons: Medical leave, parental leave, family care leave, military family leave, and safe leave (domestic violence, sexual assault, stalking).
• Benefit amount: Up to 90% of the employee's average weekly wage, subject to a maximum weekly benefit.
• Contributions: 1% of wages, split equally between employer (0.5%) and employee (0.5%). Employers with fewer than 15 employees are exempt from the employer share but must collect and remit the employee share.
• Job protection: Employees who have worked for their employer for at least 120 consecutive days are entitled to job restoration.

PFML Application Status:

☐ Employee intends to apply for Maine PFML benefits for this leave.
☐ Employee does not intend to apply for Maine PFML benefits.
☐ Leave occurs before May 1, 2026 — PFML benefits not yet available.

Coordination of Leave Programs

When an employee qualifies for multiple leave programs, the following coordination applies:

Additional Employer Policies. Employees should review their employer's handbook for supplemental leave benefits:

☐ 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 Maine Family Medical Leave (26 M.R.S.A. § 844), employees are entitled to be restored to the same or comparable position with the same status, pay, employment benefits, length of service, and seniority.

Under Maine PFML (effective May 1, 2026), employees who have worked for their employer for at least 120 consecutive days are entitled to be returned to their position or an equivalent one.

☐ 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.
• I may be eligible for Maine PFML benefits (effective May 1, 2026) providing wage replacement during qualifying leave.
• 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
• 26 M.R.S.A. § 843 — Maine Family Medical Leave Definitions
• 26 M.R.S.A. § 844 — Maine Family Medical Leave Requirements
• 26 M.R.S.A. § 850-B — Maine Paid Family and Medical Leave Program
• Maine Paid Family and Medical Leave — Official Site

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