Form 9611 PDF Details

Navigating the intricacies of applying for leave under the Family and Medical Leave Act (FMLA) can often feel daunting, especially when it involves the detailed requirements encapsulated within the 9611 form. This form serves as a comprehensive platform for employees to request leave, encompassing various situations such as the birth or adoption of a child, caring for a family member with a serious health condition, or dealing with a personal health issue that prevents them from performing their job duties. Applicants are required to provide essential information, including their name, social security number, and specific details about the leave requested, like its purpose and the anticipated starting and ending dates. Moreover, the form allows for outlining the anticipated amount of sick leave, annual leave, and leave without pay, enhancing the transparency and planning for both the employee and employer. The necessity for medical certification to support claims of serious health conditions underscores the form's thoroughness in ensuring that leave is justified. Whether it's gaining approval or understanding the grounds for disapproval, the 9611 form stands as a critical document for employees seeking FMLA leave, embodying the procedural and documentation standards set by the Department of the Treasury-Internal Revenue Service.

QuestionAnswer
Form NameForm 9611
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform irs 9611 form, form 9611 leave under, irs forms 9611, opm form 9611

Form Preview Example

6. Anticipated Ending Date

Application for Leave Under the Family and Medical Leave Act

1. Name (Please print - first, last, mi)

2. Social Security Number

3.Position (Title, Series, Grade)

4.Purpose of Leave (Check appropriate category):

a.

Birth of a son or daughter and care of such child. (5 CFR 630.1230a(l))

b.

Placement of son or daughter with you for adoption or foster care. (5 CFR 630.1230a(2))

c.

Care of your spouse, son, daughter, or parent who has a serious health condition. (5 CFR 630.1230a(3))

d.

A personal serious health condition which prohibits you from performing the essential functions of your position.

 

(5 CFR 630.1230a(4))

5. Anticipated starting date

7. Please indicate below the total number of hours of each type of leave you anticipate needing for the current condition/event.

a. Hours of sick leave

b. Hours of annual leave

c. Hours of leave without pay

8.

If leave is for a medical condition, is medical certification included with application?

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Additional information relevant to your application. (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPROVED

 

 

 

DISAPPROVED

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Name

 

 

 

14. Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Title

 

 

Date

15. Title

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Dates of FMLA

 

 

 

16. Justification for denial of FMLA

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Beginning Date:

 

b. Ending Date

a.

 

No entitlement.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

Entitlement used for current 12 month period.

 

 

 

 

 

 

 

 

c.

 

 

 

 

 

13.

 

 

Provisionally approved pending medical certification.

 

 

Unacceptable final medical certification. (Based on third option)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 9611 (Rev. 7-97)

Cat. No. 20486E

Department of the Treasury-INTERNAL REVENUE SERVICE

How to Edit Form 9611 Online for Free

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Step 1: Open the PDF form in our editor by clicking the "Get Form Button" above on this page.

Step 2: With our advanced PDF tool, you can do more than just complete blanks. Edit away and make your forms seem perfect with custom textual content incorporated, or adjust the original content to excellence - all that comes with an ability to incorporate your own images and sign the document off.

As for the blanks of this specific form, this is what you need to do:

1. Whenever submitting the 9611 form, be sure to complete all of the essential fields in its corresponding section. It will help to facilitate the work, enabling your information to be processed efficiently and appropriately.

Tips to fill in opm form 9611 portion 1

2. Just after performing this step, head on to the subsequent part and fill in the necessary details in these blanks - Additional information relevant, Name, Title, APPROVED, DISAPPROVED, Name, Date, Title, Date, Dates of FMLA, Justification for denial of FMLA, and No entitlement.

The right way to fill in opm form 9611 step 2

Always be extremely careful when completing Justification for denial of FMLA and Name, since this is the part where many people make a few mistakes.

3. Completing a Beginning Date, b Ending Date, Provisionally approved pending, No entitlement, Entitlement used for current, Unacceptable final medical, Form Rev, Cat No E, and Department of the TreasuryInternal is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Unacceptable final medical, b Ending Date, and Entitlement used for current inside opm form 9611

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