FMLA Leave Request Form - New Hampshire
FAMILY AND MEDICAL LEAVE REQUEST FORM
Employee: [FULL NAME]
Employee ID, if used: [________________]
Job title and work location: [________________]
Employer / department: [________________]
Supervisor or HR recipient: [________________]
Date submitted: [__/__/____]
LEAVE REQUEST
I request that my employer evaluate the leave described below under the federal Family and Medical Leave Act. Please assess coverage, eligibility, the qualifying reason, and available leave. This form records my request and does not decide those matters.
Reason for leave (select the reason that fits):
☐ Birth of my child and care for that child.
☐ Placement of a child with me for adoption or foster care.
☐ Care for my spouse, child, or parent with a serious health condition. Relationship: [________________].
☐ My own serious health condition that prevents me from performing my job functions.
☐ Qualifying military exigency involving my spouse, child, or parent.
☐ Care for a covered servicemember who is my spouse, child, parent, or next of kin. Relationship: [________________].
Brief explanation needed to identify the request: [________________]. Do not place detailed medical records in this form; use the employer's designated certification process if requested.
Expected first day of leave: [__/__/____]
Expected last day, if known: [__/__/____]
Date I first learned leave would be needed: [__/__/____]
Prior notice given, if any (date and to whom): [________________]
Requested schedule:
☐ Continuous leave.
☐ Intermittent leave; estimated frequency and duration: [________________].
☐ Reduced work schedule; current schedule [________________], proposed schedule [________________].
The proposed schedule is based on [known appointment dates, expected care needs, or other facts]: [________________]. I understand that an intermittent or reduced schedule is subject to the conditions in 29 U.S.C. § 2612(b); this form does not assert that every reason qualifies for it.
Contact during leave: [PREFERRED MAIL OR EMAIL AND PHONE, IF ANY]
Urgent work handoff contact or arrangements: [________________]
I ask HR to tell me what information or certification it needs and how my requested leave will be handled alongside any other leave or paid benefit for which I may apply.
Employee signature: [________________]
Date: [__/__/____]
EMPLOYER RECEIPT
Received by [NAME / ROLE] on [__/__/____] by [METHOD]. This block acknowledges receipt only; it is not a coverage, eligibility, certification, or leave designation decision.
SOURCE
This template is provided for informational purposes only by ezel.ai and does not constitute legal advice.
About this template
- Last updated
- November 2, 2026
- Citations checked
- November 2, 2026
- Jurisdiction
- New Hampshire
- Category
- Employment & HR
Legal authority
- 29 U.S.C. § 2612(a)(1), (a)(3), (b) (FMLA leave reasons and schedules)
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on November 2, 2026.
29 U.S.C. § 2612(a)(1) (checked November 2, 2026): "an eligible employee shall be entitled to a total of 12 workweeks of leave during any 12-month period for one or more of the following"
29 U.S.C. § 2612(a)(3) (checked November 2, 2026): "an eligible employee who is the spouse, son, daughter, parent, or next of kin of a covered servicemember shall be entitled to a total of 26 workweeks of leave"
29 U.S.C. § 2612(b) (checked November 2, 2026): "Leave under subparagraph (A) or (B) of subsection (a)(1) shall not be taken by an employee intermittently or on a reduced leave schedule unless the employee and the employer of the employee agree otherwise."
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