"Request Form for Maternity Leave Donation" - Nebraska

Request Form for Maternity Leave Donation is a legal document that was released by the Nebraska Department of Administrative Services - a government authority operating within Nebraska.

Form Details:

  • The latest edition currently provided by the Nebraska Department of Administrative Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Administrative Services.

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Request Form for Maternity Leave Donation
Name (Please Print): ______________________________________________________
Employee ID Number: _____________________________________________________
Agency/Office Location: ____________________________________________________
Numbers of Hours requested:_________________________________________________
FML Approval Notice and copy of FML Doctor’s Certification (if necessary) is attached.
Employee Signature: _________________________________ Date: _________________
Human Resource Use Only:
____Eligible for Maternity Leave Donations
Copy to Employee ____________ (date)
____Ineligible for Maternity Leave Donations
Reason:
________________________________________________________________________________
________________________________________________________________________________
Verified by ____________________________________________ Date ______________________
(Human Resource Contact)
Request Form for Maternity Leave Donation
Name (Please Print): ______________________________________________________
Employee ID Number: _____________________________________________________
Agency/Office Location: ____________________________________________________
Numbers of Hours requested:_________________________________________________
FML Approval Notice and copy of FML Doctor’s Certification (if necessary) is attached.
Employee Signature: _________________________________ Date: _________________
Human Resource Use Only:
____Eligible for Maternity Leave Donations
Copy to Employee ____________ (date)
____Ineligible for Maternity Leave Donations
Reason:
________________________________________________________________________________
________________________________________________________________________________
Verified by ____________________________________________ Date ______________________
(Human Resource Contact)