FAMILY AND MEDICAL LEAVE REQUEST FORM

Federal FMLA, New Jersey Family Leave Act & NJ Family Leave Insurance

(29 U.S.C. §§ 2601 et seq. | N.J. Stat. Ann. §§ 34:11B-1 et seq. | N.J. Stat. Ann. §§ 43:21-39.1 et seq.)

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Federal FMLA Overview
4. New Jersey State Leave Provisions
5. Type of Leave Requested
6. Leave Schedule
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits During Leave
11. New Jersey-Specific Notices
12. Employee Certification & Signature
13. Employer Response
14. Sources and References

1. EMPLOYEE INFORMATION

2. EMPLOYER INFORMATION

3. FEDERAL FMLA OVERVIEW

Eligibility Requirements (29 U.S.C. § 2611(2)):
- Employed by a covered employer (50+ employees within 75 miles)
- Worked for the employer for at least 12 months (need not be consecutive)
- Worked at least 1,250 hours during the 12 months preceding the leave
- Works at a location where the employer has 50+ employees within 75 miles

Leave Entitlement:
- Up to 12 workweeks of unpaid, job-protected leave in a 12-month period
- Up to 26 workweeks for military caregiver leave (29 U.S.C. § 2612(a)(3))

Qualifying Reasons (29 U.S.C. § 2612(a)(1)):
- ☐ Birth of a child and bonding within the first 12 months
- ☐ Placement of a child for adoption or foster care and bonding within the first 12 months
- ☐ Care for a spouse, child, or parent with a serious health condition
- ☐ Employee's own serious health condition rendering them unable to perform essential job functions
- ☐ Qualifying exigency arising from a family member's military service
- ☐ Care for a covered servicemember with a serious injury or illness (26 weeks)

4. NEW JERSEY STATE LEAVE PROVISIONS

A. New Jersey Family Leave Act (NJFLA) — N.J. Stat. Ann. §§ 34:11B-1 et seq.

Current Eligibility (before July 17, 2026):
- Employer has 30+ employees (private sector) or any number (public sector)
- Employee has worked for the employer for 12 months and at least 1,000 hours in the prior 12 months

Expanded Eligibility (eff. July 17, 2026 — A-3451/S-2950):
- Employer threshold reduced to 15+ employees (private sector)
- Employee eligibility reduced to 3 months employment and 250 hours worked in prior 12 months
- Further phase-downs: 10+ employees (July 2027), 5+ employees (July 2028)

NJFLA Leave Entitlement:
- Up to 12 weeks of job-protected leave in a 24-month period
- Qualifying reasons: bonding with a new child, care for a family member with a serious health condition, care resulting from an epidemic-related state of emergency
- Does NOT cover the employee's own serious health condition (use FMLA or TDI for that)

B. NJ Temporary Disability Insurance (TDI) — N.J. Stat. Ann. §§ 43:21-25 et seq.

• Provides partial wage replacement for the employee's own non-work-related illness, injury, or pregnancy-related disability
• Duration: up to 26 weeks of benefits
• Funded by employee payroll deductions
• Runs concurrently with FMLA leave for the employee's own serious health condition

C. NJ Family Leave Insurance (FLI) — N.J. Stat. Ann. §§ 43:21-39.1 et seq.

• Provides partial wage replacement for bonding with a new child or caring for a family member with a serious health condition
• Duration: up to 12 weeks of benefits in a 12-month period
• 2026 maximum weekly benefit: $1,119
• 2026 contribution rate: 0.23% on first $171,100 in covered wages
• Eligibility: 20 weeks earning $310+/week, or $15,500 total in base year
• Funded 100% by employee payroll deductions — no employer contribution
• Effective July 17, 2026: FLI recipients receive job protection (same as NJFLA leave)

5. TYPE OF LEAVE REQUESTED

Select all that apply:

Federal FMLA Qualifying Reasons:
☐ Birth of child / prenatal care / pregnancy-related incapacity
☐ Bonding with newborn child (within 12 months of birth)
☐ Placement of child for adoption or foster care
☐ Bonding with newly placed child (within 12 months of placement)
☐ Employee's own serious health condition
☐ Care for spouse with a serious health condition
☐ Care for child with a serious health condition
☐ Care for parent with a serious health condition
☐ Qualifying exigency — military deployment
☐ Military caregiver leave (26-week entitlement)

NJ-Specific Leave:
☐ NJFLA leave — bonding with new child
☐ NJFLA leave — care for family member with serious health condition
☐ NJ TDI — employee's own disability/pregnancy
☐ NJ FLI — bonding with new child
☐ NJ FLI — care for family member with serious health condition

Name of family member (if applicable): [________________________________]
Relationship to employee: [________________________________]

Brief description of reason for leave:
[________________________________]
[________________________________]

6. LEAVE SCHEDULE

Federal FMLA Tracking:

NJFLA Tracking (24-month period):

7. INTERMITTENT OR REDUCED SCHEDULE LEAVE

☐ Not applicable — I am requesting continuous leave

☐ Intermittent leave — I need to take leave in separate blocks of time

☐ Reduced schedule — I need to reduce my usual work schedule

If intermittent or reduced schedule leave is requested:

8. MEDICAL CERTIFICATION

☐ Medical certification is attached (DOL Form WH-380-E or WH-380-F)
☐ Medical certification will be provided by: [__/__/____]
☐ Military certification is attached (DOL Form WH-384 or WH-385)
☐ NJ TDI/FLI claim filed separately with NJ Division of Temporary Disability
☐ No medical certification required for this leave type

Certifying Healthcare Provider:

9. JOB RESTORATION RIGHTS

Federal FMLA Restoration (29 U.S.C. § 2614(a)):
- Employee is entitled to return to the same position or an equivalent position with equivalent pay, benefits, and working conditions
- Key employees (salaried, among the highest-paid 10%) may be subject to limited exceptions

NJFLA Restoration (N.J. Stat. Ann. § 34:11B-7):
- Employee is entitled to reinstatement to the same or equivalent position
- NJFLA does not contain a "key employee" exception

TDI/FLI Job Protection (eff. July 17, 2026):
- Employees receiving TDI or FLI benefits are entitled to the same job protections as employees returning from NJFLA leave
- This is a significant expansion — previously, TDI/FLI alone did not provide job protection

10. BENEFITS DURING LEAVE

Health Insurance Continuation:
- FMLA: Employer must maintain group health insurance under the same terms (29 U.S.C. § 2614(c))
- NJFLA: Employer must continue health benefits during NJFLA leave on the same terms
- Employee must continue to pay their share of premiums

NJ Wage Replacement Programs:

Additional Paid Leave Substitution:

☐ I elect to substitute accrued paid leave concurrently with FMLA/NJFLA leave
☐ I intend to file for NJ TDI benefits
☐ I intend to file for NJ FLI benefits
☐ I understand the employer may require substitution of accrued paid leave

11. NEW JERSEY-SPECIFIC NOTICES

NJ Division on Civil Rights (DCR):
- Employees who believe they have been discriminated against for exercising leave rights may file a complaint with the NJ DCR within 2 years of the alleged discriminatory act
- Contact: NJ Division on Civil Rights, 31 Clinton Street, Newark, NJ 07102 | Phone: (973) 648-2700

NJ Division of Temporary Disability and Family Leave Insurance:
- TDI/FLI claims: https://myleavebenefits.nj.gov/
- Phone: (609) 292-7060

2026 NJFLA Amendment Timeline:
- Effective July 17, 2026: Employer threshold lowered to 15+ employees; employee eligibility reduced to 3 months/250 hours; TDI/FLI job protection added
- Effective July 17, 2027: Employer threshold lowered to 10+ employees
- Effective July 17, 2028: Employer threshold lowered to 5+ employees

NJ SAFE Act (N.J. Stat. Ann. § 34:11C-1 et seq.):
- Up to 20 days of unpaid leave for victims of domestic violence or sexual assault

12. EMPLOYEE CERTIFICATION & SIGNATURE

I certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that:

• Federal FMLA leave is unpaid unless I elect (or am required) to substitute accrued paid leave or receive TDI/FLI benefits
• NJFLA provides up to 12 weeks of job-protected leave in a 24-month period for family care/bonding
• NJ FLI provides up to $1,119/week for up to 12 weeks (2026 rates)
• I must provide 30 days' advance notice when the need for leave is foreseeable
• I must provide medical certification if requested by my employer
• I must make reasonable efforts to schedule foreseeable medical treatment to minimize disruption
• Providing false or misleading information may result in denial of leave and/or disciplinary action

Employee Signature: [________________________________]
Printed Name: [________________________________]
Date: [__/__/____]

13. EMPLOYER RESPONSE

☐ APPROVED — Leave is designated as FMLA-qualifying and/or NJFLA-qualifying
☐ PROVISIONALLY APPROVED — Pending receipt of medical certification
☐ DENIED — Employee does not meet eligibility requirements
☐ MORE INFORMATION NEEDED — Specify: [________________________________]

Leave Designation:
☐ Federal FMLA ☐ NJFLA ☐ Both (concurrent) ☐ NJ TDI eligible ☐ NJ FLI eligible

Designated Leave Period: [__/__/____] through [__/__/____]

Reason for denial (if applicable):
[________________________________]

14. SOURCES AND REFERENCES

• Family and Medical Leave Act of 1993, 29 U.S.C. §§ 2601–2654
• FMLA Regulations, 29 C.F.R. Part 825
• New Jersey Family Leave Act, N.J. Stat. Ann. §§ 34:11B-1 to 34:11B-16
• NJ Temporary Disability Insurance, N.J. Stat. Ann. §§ 43:21-25 to 43:21-56
• NJ Family Leave Insurance, N.J. Stat. Ann. §§ 43:21-39.1 to 43:21-39.6
• 2026 NJFLA Amendments, A-3451/S-2950 (signed Jan. 17, 2026, eff. July 17, 2026)
• U.S. Department of Labor FMLA Forms: https://www.dol.gov/agencies/whd/fmla/forms
• NJ Division on Civil Rights: https://www.njoag.gov/about/divisions-and-offices/division-on-civil-rights-home/
• NJ My Leave Benefits: https://myleavebenefits.nj.gov/

This document is provided for informational purposes only and does not constitute legal advice. Consult a qualified New Jersey attorney before use.