"Time off Request Form"

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TIME OFF REQUEST FORM
Household Employee:____________________________________
PERSONAL TIME OFF REQUESTS
Paid Time Off: Begins to accrue after 90 days of employment. Requests for PTO of two or more
days must be submitted at least two weeks in advance.
Bereavement Leave: Up to three days of paid leave is available for a death in the immediate
family.
Start date
End date
Hours
Personal time off
Bereavement
Jury duty/witness
Military service
Total paid time off
------------------------------------------------------------------------------------------------------
VACATION REQUESTS
Vacation Instructions: Please submit your vacation request at least four weeks in advance of
START DATE.
Start date
End date
Hours
Employer
approval
st
1
choice
nd
2
choice
rd
3
choice
Total paid time off
Household Employee Name:________________Date:____________
Employer Name:__________________________Date:___________
TIME OFF REQUEST FORM
Household Employee:____________________________________
PERSONAL TIME OFF REQUESTS
Paid Time Off: Begins to accrue after 90 days of employment. Requests for PTO of two or more
days must be submitted at least two weeks in advance.
Bereavement Leave: Up to three days of paid leave is available for a death in the immediate
family.
Start date
End date
Hours
Personal time off
Bereavement
Jury duty/witness
Military service
Total paid time off
------------------------------------------------------------------------------------------------------
VACATION REQUESTS
Vacation Instructions: Please submit your vacation request at least four weeks in advance of
START DATE.
Start date
End date
Hours
Employer
approval
st
1
choice
nd
2
choice
rd
3
choice
Total paid time off
Household Employee Name:________________Date:____________
Employer Name:__________________________Date:___________