Leave without pay request form 1002.doc - corporate rfmh-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employee Name and SS Number clearly in the designated fields.
3. Fill out your Mailing Address, including City, State, and ZIP code. Ensure accuracy for communication purposes.
4. Provide your Home and Work Telephone numbers in the respective fields.
5. Indicate your Work Location and Supervisor's name for reference.
6. Specify your Percentage of Effort and Date of Employment to give context to your request.
7. In the REASON FOR LEAVE section, provide a brief explanation of why you are requesting leave without pay.
8. If applicable, detail any ADDITIONAL REQUESTS such as a temporary reduction in effort.
9. Fill in the anticipated dates of leave, including both Beginning and Return dates.
10. If you have any Paid Leave to be used, specify the hours for Personal Leave, Holiday, and Vacation accordingly.
11. Complete the Health Insurance Certification section if you wish to maintain coverage during your leave.
12. Sign and date the Employee Certification at the bottom of the form before submission for approval.

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