FMLA Leave Request Form - Mississippi

FMLA LEAVE REQUEST FORM — MISSISSIPPI

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. Mississippi-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, or parent 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.

☐ 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 in a single 12-month period).

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. 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. Mississippi-Specific Considerations

No State FMLA Supplement. Mississippi has not enacted a state-level family or medical leave law for private-sector employees. Employees rely exclusively on the federal FMLA and employer-provided leave policies.

No State Paid Family Leave Program. Mississippi does not operate a state-funded paid family or medical leave insurance program for private-sector workers. No mandatory payroll contributions are collected for state paid leave benefits.

No State Mandatory Paid Sick Leave. Mississippi does not require private-sector employers to provide paid sick leave.

State Employees Paid Parental Leave Act (HB 1063, effective January 1, 2026)

Mississippi enacted HB 1063 during the 2025 Regular Session. Its core benefit applies to an employee of a state agency, department, or institution who has served at least 12 consecutive months in a full-time permanent position and is the child's primary caregiver:

• Primary-caregiver benefit: Six (6) weeks / 240 hours at 100% of regular salary.
• Qualifying events: Birth of the employee's biological child or legal adoption of a child under age 18.
• Use period: The leave must be taken within 12 weeks after birth or adoption and may be used only once in a 12-month period.
• Coordination: The leave runs concurrently with federal FMLA leave where applicable; legal state and federal holidays are not charged against it.
• Scope: Private-sector workers are not covered. Public-school and community/junior-college districts may choose to adopt a substantially similar policy.

Is the employee a Mississippi state government employee?

☐ Yes — the employee meets the Act's state-service, full-time permanent position, primary-caregiver, and qualifying-event requirements.
☐ No — Federal FMLA and employer policies apply.

Mississippi Employment Protection

While Mississippi lacks a comprehensive anti-discrimination employment statute for the private sector, employees are protected by:

• Federal protections: Title VII of the Civil Rights Act of 1964 (including pregnancy discrimination), the ADA, and the Pregnancy Discrimination Act apply to Mississippi employers with 15+ employees.
• Workers' compensation: If the serious health condition is work-related, concurrent rights under Mississippi Workers' Compensation Law (Miss. Code Ann. § 71-3-1 et seq.) may apply.

Local Government and Other Public Employees

Mississippi state employees may have additional leave benefits under Miss. Code Ann. §§ 25-3-93 and 25-3-95 and agency policies. Public-school and community/junior-college districts may adopt a paid-parental-leave policy substantially similar to the state program; other public employees should check the governing employer policy and applicable law.

Additional Employer Policies:

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

9. Job Restoration Rights

Under federal FMLA, eligible employees are entitled to:

• Be restored to the same position or an equivalent position with equivalent pay, benefits, and other terms and conditions of employment upon return from leave.
• Continued group health insurance coverage during leave on the same terms as if the employee had continued to work.

☐ 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.
• Mississippi does not have a state-funded paid family leave program for private-sector employees.
• 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
• 29 C.F.R. Part 825 — FMLA Regulations
• HB 1063, 2025 Regular Session — signed by Governor (official PDF)
• NOLO — Family and Medical Leave in Mississippi

This document is a template only and does not constitute legal advice. Legal review is strongly recommended before implementation. Mississippi employers should ensure compliance with all applicable federal and state employment laws.