FMLA Leave Request Form

provide explanatory notes.
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FMLA LEAVE REQUEST FORM — MINNESOTA

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. Minnesota-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, and recovery (up to 12 weeks under MN Paid Leave).

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

☐ 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 MN Paid Leave).

☐ Safety Leave — To address the effects of domestic abuse, sexual assault, or stalking against the employee or a family member (up to 12 weeks under MN Paid Leave).

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

☐ 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.
• Employee eligibility: 12 months of service, 1,250 hours worked, 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.
Minnesota Paid Leave: 30 days' advance notice if foreseeable; 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. Minnesota-Specific Considerations

Minnesota Paid Leave Law (Minn. Stat. ch. 268B)

Effective January 1, 2026, Minnesota's Paid Leave program provides comprehensive paid leave benefits:

Leave Entitlements:

• Medical Leave: Up to 12 weeks per benefit year for the employee's own serious health condition, including pregnancy and childbirth.
• Family Leave: Up to 12 weeks per benefit year for bonding with a new child, caring for a family member with a serious health condition, safety leave (domestic abuse/sexual assault/stalking), or qualifying military exigency.
• Combined maximum: Up to 20 weeks per benefit year when an employee qualifies for both medical and family leave.

2026 Benefit Amounts:

• Maximum weekly benefit: $1,423.00.
• Benefit calculation: Sliding scale — 90% of wages up to 50% of the state average weekly wage, down to 55% of wages exceeding 100% of the state average weekly wage.
• Benefits are not subject to a waiting period for the first occurrence in a benefit year.

2026 Premium Rates:

• Total premium rate: 0.88% of wages.
• Employers may collect up to 0.44% from employees; the remainder is the employer's share.
• Self-employed individuals may opt in.

Eligibility:

• Employees must have earned at least $3,500 in wages during the base period (high quarter equivalent).
• Coverage applies to nearly all workers in Minnesota, regardless of employer size, including part-time workers.
• Limited exception for certain seasonal workers.

Expanded Family Definition:
Under MN Paid Leave, "family member" includes spouse, registered domestic partner, child (any age), parent, sibling, grandchild, grandparent, and other individuals with a close association equivalent to a family relationship.

Bonding Leave for 2025 Births

Parents who welcomed a child in 2025 may qualify for paid bonding leave benefits in 2026, provided the application is approved within 12 months of the child's arrival (birth, adoption, or foster placement).

Minnesota Parenting Leave Act (Minn. Stat. § 181.940–181.944)

The Minnesota Parenting Leave Act provides additional unpaid leave protections:

• Employer threshold: Employers with 21 or more employees at one site.
• Leave duration: Up to 12 weeks of unpaid leave for the birth or adoption of a child.
• Eligibility: Employees who have worked for the employer for at least 12 months and at least half-time (average 20+ hours per week).
• Job protection: Employees are entitled to restoration to the same or comparable position.
• School conference leave: Employees may take up to 16 hours per 12-month period for school conferences and activities.

Pregnancy and Parental Leave (Minn. Stat. § 181.9413)

Minnesota law entitles employees to use accrued sick leave to care for a child following birth or adoption, on the same terms as leave for the employee's own illness.

Minnesota Paid Leave Application

Employee intends to apply for Minnesota Paid Leave benefits:

☐ Yes — through the Minnesota Paid Leave system (paidleave.mn.gov).
☐ No — employee will use accrued paid leave or take unpaid leave only.

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 Minnesota Paid Leave (Minn. Stat. ch. 268B), employees are entitled to job restoration upon return from approved paid leave. Retaliation for taking paid leave is prohibited.

Under the Minnesota Parenting Leave Act, employees are entitled to restoration to the same or comparable position with the same pay, benefits, and conditions.

☐ 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 Minnesota Paid Leave benefits providing wage replacement during qualifying leave.
• Federal FMLA leave may run concurrently with Minnesota Paid Leave.
• I must provide medical certification if requested.
• I must file an application with the Minnesota Paid Leave program 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
• Minn. Stat. ch. 268B — Minnesota Paid Leave Law
• Minn. Stat. § 181.940–181.944 — Minnesota Parenting Leave Act
• Minnesota Paid Leave — Official Site
• Minnesota House — Family, Medical Leave Law Summary

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