Form MS406-LB "State Employees' Leave Bank Appeal Form for Denial of Leave" - Maryland

What Is Form MS406-LB?

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

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the Maryland Department of Budget and Management;
  • 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 MS406-LB by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

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Download Form MS406-LB "State Employees' Leave Bank Appeal Form for Denial of Leave" - Maryland

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STATE EMPLOYEES’ LEAVE BANK
APPEAL FORM FOR DENIAL OF LEAVE
(ALL FIELDS ARE REQUIRED)
NAME:
DATE:
HOME ADDRESS:
AGENCY NAME:
JOB TITLE:
My request for leave should be reconsidered because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
In addition to submitting your appeal, please have your treating physician(s) fax any
medical records that support your Leave Bank absence. The medical documentation
should address only the period of time you need leave from the Leave Bank. It must
include detailed information that explains the severity and duration of your medical
condition(s). Please refer to the State Employees’ Leave Bank – Medical Documentation
form you received with your denial letter for examples of the type of documentation that
should be provided. The appeal and the records may be faxed to 410-333-5440.
MS 406-LB
Rev. 9/2017
STATE EMPLOYEES’ LEAVE BANK
APPEAL FORM FOR DENIAL OF LEAVE
(ALL FIELDS ARE REQUIRED)
NAME:
DATE:
HOME ADDRESS:
AGENCY NAME:
JOB TITLE:
My request for leave should be reconsidered because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
In addition to submitting your appeal, please have your treating physician(s) fax any
medical records that support your Leave Bank absence. The medical documentation
should address only the period of time you need leave from the Leave Bank. It must
include detailed information that explains the severity and duration of your medical
condition(s). Please refer to the State Employees’ Leave Bank – Medical Documentation
form you received with your denial letter for examples of the type of documentation that
should be provided. The appeal and the records may be faxed to 410-333-5440.
MS 406-LB
Rev. 9/2017