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State, Zip Code]Dear
[Employee Name]:On [date of request], you notified us of your need to take a leave
of absence beginning on [beginning date] until [ending date] due to
> The birth of a child, or the placement of a child with you
for adoption or foster care.
> A serious health condition that makes you unable to perform
the essential functions of your job.
> A serious health condition affecting your (spouse/child/parent),
for which you are needed to provide care.
At this time, you are not eligible for leave under federal or
state leave laws. However, you have met eligibility requirements for an unpaid
personal leave of absence.
request for a personal leave of absence from [beginning date] until [ending date]
has been approved.
Failure to return to work upon the
expiration of the leave of absence or refusing an offer of reinstatement for
which you are qualified will be considered a voluntary resignation of
If you have any questions, please contact me at [phone
[HR Representative’s name and signature]
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