FMLA Leave Request Letter Template – Free
Use this free FMLA leave request letter (United States): fill it in online, download it as Word or PDF, and follow our step-by-step guide – where to send it, whether it needs notarizing, what to attach and mistakes to avoid.
| Country | 🇺🇸 United States |
|---|---|
| Document type | Jobs & HR |
| Format | Word, PDF & fill in online |
| Cost | Free |
| Time to complete | about 5 minutes |
| Notarization | Not required |
What is this letter for?
The Family and Medical Leave Act gives eligible employees up to 12 weeks of unpaid, job-protected leave per year for qualifying reasons. Give 30 days’ notice when the leave is foreseeable.
Where do you send it?
Give it to HR (or your manager) at least 30 days before foreseeable leave.
Does it need to be notarized?
Not required. No notarization; your employer may require medical certification on its own form.
What you need before you start
- Reason category (own health, family care, new child)
- Expected start date and duration
- Medical certification if requested
How to use this template
- Click each yellow field inside the letter and type your details directly (Enter jumps to the next field).
- Read the text through; the “Edit” button lets you change any sentence.
- Click “Word”, “PDF” or “Copy”, then sign and send.
Free template : FMLA leave request letter
Your full name
Street address
City, State ZIP
Phone | Email
Date
HR manager name
Human Resources
Company name
Re: Request for FMLA leave
Dear Recipient name,
I am writing to request leave under the Family and Medical Leave Act for qualifying reason.
I expect my leave to begin on Start date and to last approximately duration. If intermittent, describe the schedule.
I will provide any certification required and keep you informed of any changes.
Sincerely,
Your full name
⚠️ Disclaimer: this template is for general guidance only and is not legal advice. Always check the requirements of the organization you are writing to before sending it.
Common mistakes to avoid
- ❌ Waiting until the last minute for planned leave.
- ❌ Missing the certification deadline.
- ❌ Not confirming eligibility first.
Tips before you send it
- Give 30 days’ notice when possible.
- Return the certification within the deadline.
- Ask how your health insurance continues.
Frequently asked questions
Who is eligible for FMLA?
Employees who worked 12 months and 1,250 hours for a covered employer, at a site with 50+ employees within 75 miles.
Is FMLA leave paid?
No, it is unpaid, though some states and employers offer paid leave.
Where do I send this letter (FMLA leave request letter)?
Give it to HR (or your manager) at least 30 days before foreseeable leave.
Does this letter (FMLA leave request letter) need to be notarized?
Not required – No notarization; your employer may require medical certification on its own form.