Volunteer Emergency-Responder Work-Absence Notice and Verification Packet - Florida
FLORIDA DISASTER-VOLUNTEER LEAVE REQUEST AND COMPLETION PACKET
Florida state-agency employees — Fla. Stat. § 110.120
1. ELIGIBILITY WORKSHEET
| Field | Entry |
|---|---|
| Employee | [________________________________] |
| State agency | [________________________________] |
| Position / supervisor | [________________________________] |
| Nonprofit organization | [________________________________] |
| Organization tax status | ☐ § 501(c)(3) ☐ § 501(c)(4) |
| Volunteer agreement date | [__/__/____] |
Confirm all:
- ☐ The organization and employee have an agreement for nonpaid disaster response or recovery services.
- ☐ A governor of a U.S. state or territory issued an executive order or proclamation declaring the disaster emergency.
- ☐ Requested leave plus prior § 110.120 leave will not exceed 120 working hours in a twelve-month period.
- ☐ The employee understands approval is discretionary.
Disaster location: [________________________________]
- ☐ Within Florida
- ☐ Another U.S. state or territory; agency-head approval is required
2. EMPLOYEE REQUEST
Requested paid leave: [START] through [END], totaling [________] working hours.
Volunteer services: [________________________________]
Declaration authority / date / identifier: [________________________________]
Prior § 110.120 leave during the relevant twelve-month period: [________] hours.
I request agency approval after verification of my volunteer status. I understand that, while serving under this section, I am not deemed a state employee for workers' compensation purposes.
Employee signature: __________________________ Date: ______________
3. NONPROFIT VERIFICATION
I verify that [EMPLOYEE] entered into an agreement with [ORGANIZATION], a tax-exempt organization under Internal Revenue Code § 501(c)(3) or § 501(c)(4), to provide nonpaid services for disaster response or recovery.
Expected service period and duties: [________________________________]
Organization representative: __________________ Date: ______________
Official contact: [________________________________]
4. AGENCY DECISION
- ☐ Volunteer status verified
- ☐ Approved for [________] paid working hours
- ☐ Out-of-state or territorial service approved by agency head
- ☐ More information required: [________________________________]
- ☐ Denied after discretionary review: [________________________________]
Agency representative: ________________________ Date: ______________
Agency head, if required: ______________________ Date: ______________
5. COMPLETION ATTESTATION
I attest that I completed volunteer service for the disaster identified above.
| Item | Entry |
|---|---|
| Actual service period | [________________________________] |
| Working hours charged to leave | [________________________________] |
| Disaster response or recovery services provided | [________________________________] |
Employee signature: __________________________ Date: ______________
Agency receipt / payroll reconciliation: [________________________________]
6. DELIVERY LOG
| Date | Item | From / to | Method | Receipt |
|---|---|---|---|---|
| [________] | [________________] | [________________] | [________] | [________________] |
| [________] | [________________] | [________________] | [________] | [________________] |
OFFICIAL SOURCE VERIFIED
About this template
- Last updated
- August 10, 2026
- Citations checked
- August 10, 2026
- Jurisdiction
- Florida
- Category
- Employment & HR
Legal authority
- Fla. Stat. § 110.120 (discretionary paid disaster-volunteer leave for state-agency employees; nonprofit agreement, agency approval, 120-hour limit, verification, interstate approval, attestation, and workers' compensation rule)
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 August 10, 2026.
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