Form 9611 (Rev 6-2014) Application for Leave Under the Family and Medical Leave Act-2026

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4.1 out of 5

40 votes

The document is an application form for leave under the Family and Medical Leave Act (FMLA), allowing employees to request time off for various family and medical reasons. It includes sections for personal information, type of leave requested, reasons for the request, anticipated leave dates, and necessary certifications. The form also outlines approval or disapproval criteria by management.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the first field. Ensure that you print clearly for legibility.
Fill in your SEID, which is essential for identification purposes.
Select the type of request you are making: Regular FMLA, Military Related Exigency Provision, or Military Family FMLA.
Complete your position title, series, and grade to provide context about your employment status.
Indicate your organization/function to help process your request efficiently.
Check all applicable reasons for your leave request from the provided options, ensuring you select those that apply to your situation.
Specify if you are currently using FMLA for any other purpose by selecting 'Yes' or 'No.'
Enter anticipated starting and ending dates for your leave request.
Detail how many hours of each type of leave you anticipate using for this request.
If applicable, confirm whether you've included necessary medical certifications or additional documentation as required.
Sign and date the form at the bottom before submitting it for approval from your manager.

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Versions	Form popularity	Fillable & printable
2014	4.1 Satisfied (40 Votes)
1997	4.8 Satisfied (251 Votes)

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Can I complete and sign my fmla employee online?

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What are the rules for FMLA in California?

In order to be eligible to take leave under the FMLA, an employee must (1) work for a covered employer, (2) work 1,250 hours during the 12 months prior to the start of leave, (3) work at a location where 50 or more employees work at that location or within 75 miles of it, and (4) have worked for the employer for 12

What is the Family Medical Leave Act in California?

The FMLA/CFRA entitles eligible employees up to twelve (12) workweeks of unpaid, job-protected leave each calendar year (January 1st December 31st) for specified family and medical reasons.

Who is eligible for the family leave Act in California?

To take the leave, you must have recently had a child, have a serious health condition, or be taking care of a family member with a serious health condition.

irs form 9611

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Do you get paid on FMLA in CA?

In reality, while FMLA leave is unpaid, the employer must maintain the employees health benefits under the same conditions as if they were working. Other benefits, such as seniority or paid leave accrual, may not necessarily continue to accrue during the period of FMLA leave.

What is an example of a FMLA request?

Please be advised that I hereby request an FMLA leave for a period of (number of weeks) in connection with my serious health condition. The leave is to start on (date). Attached is my medical note reflecting the need for FMLA leave. Please let me know whether you approve this leave at your earliest convenience.

What are the rules around FMLA?

Employees are eligible for leave if they have worked for their employer at least 12 months, at least 1,250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles.

What is the Family Medical Leave Act in NY?

FMLA Overview The Family Medical Leave Act provides eligible employees up to 12 weeks of unpaid, job-protected leave a year whether you are unable to work because of your own serious health condition or because you need to care for a family member with a serious health condition.

Does anxiety qualify for FMLA?

For Self: An employee can take FMLA time if they have a serious health condition that severely impacts their ability to work. Some common conditions that may qualify include depression and severe anxiety. For Family Members: An employee can take FMLA leave to provide care for their spouse, parent, or child.

Form 9611 (Rev 6-2014) Application for Leave Under the Family and Medical Leave Act-2026

Here's how it works

How to use or fill out Form 9611 (Rev 6-2014) Application for Leave Under the Family and Medical Leave Act with DocHub

See more Form 9611 (Rev 6-2014) Application for Leave Under the Family and Medical Leave Act versions

Complete this form in 5 minutes or less

Got questions?

Can I complete and sign my fmla employee online?

How to manage my leave employer from Gmail?

What are the rules for FMLA in California?

What is the Family Medical Leave Act in California?

Who is eligible for the family leave Act in California?

Security and compliance

Complete this form in 5 minutes or less

People also ask

Do you get paid on FMLA in CA?

What is an example of a FMLA request?

What are the rules around FMLA?

What is the Family Medical Leave Act in NY?

Does anxiety qualify for FMLA?

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