Form ADM4258 "Request for Leave" - Ohio

What Is Form ADM4258?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 1999;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ADM4258 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4258 "Request for Leave" - Ohio

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State of Ohio
Request For Leave
(Middle Initial)
Name
(Last)
(First)
Date
Employing Unit
I request leave
q
q
Beginning
, and
P. M.
,
A. M.
(time)
(date)
(year)
q
q
Ending
, for the following reason:
P. M.
,
A. M.
(time)
(year)
(date)
Mark Appropriate Boxes Below:
q
Sick Leave
# of Hours
(Explain)
q
q
q
# of Hours
Vacation
# of Hours
Personal
# of Hours
Compensatory
q
Leave Without Pay (Explain)
q
Name of Deceased
Relationship
Date of death
Bereavement
(Attach copy of subpoena or summons)
q
q
Jury Duty
Witness Duty
(Attach copy of orders, or other appropriate documentation, that supports request for Military leave)
q
q
Military With Pay
Military Without Pay
Event Date
Do you wish to supplement?
q
q
q
Adoption / Childbirth Leave
No
Yes
Do you wish to supplement?
q
q
q
q
Pending Disability
Pending Workers' Compensation
No
Yes
Total Hours Requested
Is this absence due to a condition for which an FMLA
Certification form is on file?
q
q
q
Yes
No
Other (Explain)
I certify that this request for leave form contains true and complete information.
I have insufficient sick leave for the above request.
I request the following in lieu of sick leave:
q
q
Personal
Vacation
q
q
Leave Without Pay
Compensatory
Signature of Employee
Administrative Action
q
q
q
q
Approved
Disapproved
Recommended
Not Recommended
Supervisor Signature
Appointing Authority Signature
Date
Date
Remarks
Remarks
ADM 4258 (Rev. 6-1999)
Copies To: Time Keeper, Manager/Supervisor, Employee
State of Ohio
Request For Leave
(Middle Initial)
Name
(Last)
(First)
Date
Employing Unit
I request leave
q
q
Beginning
, and
P. M.
,
A. M.
(time)
(date)
(year)
q
q
Ending
, for the following reason:
P. M.
,
A. M.
(time)
(year)
(date)
Mark Appropriate Boxes Below:
q
Sick Leave
# of Hours
(Explain)
q
q
q
# of Hours
Vacation
# of Hours
Personal
# of Hours
Compensatory
q
Leave Without Pay (Explain)
q
Name of Deceased
Relationship
Date of death
Bereavement
(Attach copy of subpoena or summons)
q
q
Jury Duty
Witness Duty
(Attach copy of orders, or other appropriate documentation, that supports request for Military leave)
q
q
Military With Pay
Military Without Pay
Event Date
Do you wish to supplement?
q
q
q
Adoption / Childbirth Leave
No
Yes
Do you wish to supplement?
q
q
q
q
Pending Disability
Pending Workers' Compensation
No
Yes
Total Hours Requested
Is this absence due to a condition for which an FMLA
Certification form is on file?
q
q
q
Yes
No
Other (Explain)
I certify that this request for leave form contains true and complete information.
I have insufficient sick leave for the above request.
I request the following in lieu of sick leave:
q
q
Personal
Vacation
q
q
Leave Without Pay
Compensatory
Signature of Employee
Administrative Action
q
q
q
q
Approved
Disapproved
Recommended
Not Recommended
Supervisor Signature
Appointing Authority Signature
Date
Date
Remarks
Remarks
ADM 4258 (Rev. 6-1999)
Copies To: Time Keeper, Manager/Supervisor, Employee