Human resources
Maternity leave request template (US)
A general template under US law. Laws differ from state to state, so check it against your state's law or with a lawyer licensed there. We are not a law firm and do not give legal advice.
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Preview — US standard
Parental Leave Request
To: Manager Name, Manager Title
Copy: HR Contact
From: Employee Name, Job Title, Department
Date: Request Date
I am writing to give notice that I will need leave for the Birth, Adoption or Foster Placement of my child, expected on Expected Date.
Leave Requested
| Item | Details |
| --- | --- |
| Leave start date | Leave Start Date |
| Expected return date | Expected Return Date |
| Schedule | Continuous Leave or Intermittent or Reduced Schedule |
Leave Rights
Please let me know whether this leave is covered by:
• The Family and Medical Leave Act (up to 12 weeks of job-protected leave for eligible employees)
• State paid family or medical leave, disability or pregnancy leave laws
• The Pregnant Workers Fairness Act, for any accommodations I may need before or after the birth
• Company paid parental leave policy
I would also like to use the following paid time off during the leave: Paid Time Off to Use.
Benefits
Please confirm how my health insurance will continue during the leave and how I should pay my share of premiums.
Work Handover
Before my leave, I will prepare a handover for Coverage Colleague, including: Handover Items. I will give more notice as soon as I can if the dates change, and will provide any medical certification required.
After my return, I may need break time and a private space to express breast milk, as provided by the PUMP for Nursing Mothers Act and state law: Yes or No or Not Sure.
Thank you for your support.
Employee Signature
Employee Printed Name