This is a sample form for employees to request time off under the Family and Medical Leave Act. Required to complete an Employee Request for Leave Form to request an unpaid leave of absence.Benefit forms and voluntary benefits claim forms. The Family and Medical Leave Act (FMLA) allows an eligible state employee to take up to 12 workweeks of leave per rolling 12month period. Request to Return From FMLA Leave: I should fill out the top portion of the form, notifying Human Resources of the date of my return. If the employee's request for FMLA leave is approved, the employee must complete a Leave of Absence Request form (A102). (You may request leave again in the future.