Leave of Absence or FMLA/State Leave Protection Request Form

Name of Human Resources representative

I understand that by submitting this form Teammate Care will start the leave of absence or FMLA/State Leave protection process. After submitting this form, you will receive information via email within the next five business days on required next steps in the leave or FMLA process.

This is not an information request form. If you are only seeking information on Truist leave of absence, time off or FMLA programs, do not complete this form. Close out of this form and go to Human Resources A-Z on the Truist HR intranet site.

I am requesting to start the leave of absence of FMLA/State Leave protection process.

Teammate First Name

Teammate Last Name

Teammate ID - Find next to your name in Workday (This is not your A, B, C, D or G#.)

Teammate Truist Network Logon (A,B, C, D or G #)

How much time off do you need off?

A) 14 consecutive calendar days or less at one timeB) More than 14 consecutive calendar days at one timeC) A day here, a day there (time off as-needed / intermittent time off)Combination of A and C (please specify in comments)Combination of B and C (please specify in comments) (Select this option for Maternity)I am not sure at this time (please specify in comments)

Have you filed a workers’ compensation claim?

YesNo

What is your expected delivery date?

Does your spouse or partner work for Truist?

YesNo

What is your spouse's/partner's expected delivery date?

What is the date you are expected to bring your new child into your home?

How many paid New Parent Time Off days do you plan to use? (Up to 50 days available)

Which family member is in the military?

ChildParentSpouse

What is your family member's first and last name?

Is this an in Loco Parentis Relationship?

YesNo

What is your family member's relation to you?

By checking below, I attest that my family member does meet the definition of Domestic Partner as defined by Truist.

Note: Once you navigate to the link, select +Read More to view the Domestic Partner Definition.

I attest

Please describe "Other" relationship

What is the child's age today?

17 or Under18 or Older

If your child is 18 years of age or older, is your child incapable of self-care because of a mental or physical disability?

YesNo

Please provide first date that you missed (in the past 12 months) or expect to miss work due to this absence need.

If the date you entered is in the past, are you seeking retro-active FMLA/state leave protection coverage back to this date?

YesNoThe date entered is in the future

What date are you seeking to begin FMLA/state leave protection?

What is your expected return to work date from your consecutive absence period? If unsure, best estimate is fine.

Please provide the best personal phone number to reach you on when you are absent.

Please confirm whether or not you have notified your manager of this request

Yes No

I understand my manager will receive a general notification of my leave request. Therefore, I will notify my manager about my request within the next two business days. (Teammates should not disclose personal medical information to their managers.)

I understand and will notify my manager.

Please provide any additional comments you want your leave specialist to know about your situation.

By checking below, I attest that I understand and agree that if, for any reason, I am placed on unpaid leave of absence, I agree that Truist may recoup any funds paid to me for time not worked due to my leave of absence on the next available check.

I attest

By checking below, I attest that I understand and agree that my benefit premiums and 401(k) loan repayments, if applicable, will automatically be drafted from the same account in which my Truist pay is/was deposited. Premiums will be drafted on the 15th and the last business day of each month. If the 15th falls on a weekend or Holiday, my account will be drafted the business day prior. If the draft is rejected two consecutive times, my benefits will be canceled. My next opportunity to enroll in benefits will be during annual enrollment for the next year or when I return to active status. It will be my responsibility to request a benefit change by contacting Teammate Care at 800-716-2455 within 31 days of my return to active employment status.

I attest