Human resources
Unpaid 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.
Fill in this template- Written for US law, with your state left to fill in
- Fill the blanks in your browser
- Print, or save as PDF or Word
- No account needed to start
Preview — US standard
Unpaid Leave of Absence Request
To: Manager Name, Manager Title
Copy: HR Contact
From: Employee Name, Job Title, Department
Date: Request Date
I am requesting an unpaid leave of absence as follows:
| Item | Details |
| --- | --- |
| Leave start date | Leave Start Date |
| Expected return date | Return Date |
| Total length | Total Length |
| Reason | Reason, in as much detail as you choose to share |
If this leave may qualify for job-protected leave under the Family and Medical Leave Act (FMLA), state family or medical leave law, military leave (USERRA) or as a disability accommodation, please let me know, and I will provide any certification needed.
I understand that I may need to pay my share of health insurance premiums while on unpaid leave. Please tell me how and when to pay them, and how the leave affects my other benefits and paid time off.
Before my leave, I will hand over my work to Coverage Colleague as follows: Handover Plan. While I am away, I can be reached at Contact During Leave for urgent matters only.
Thank you for considering this request.
Employee Signature
Employee Printed Name
For Company Use
Decision: Approved, Approved with Changes or Not Approved
Notes: Decision Notes
Approved by: Approver Name and Signature Date: Decision Date