Orion ISO FS MN Paid Family Medical Leave

Orion ISO FS MN Paid Family Medical Leave
Fill out this form to notify your household employer of your intent to apply for MN Paid Family Medical Leave with the State of Minnesota. To apply for a leave of absence, please visit https://mn.gov/deed/paidleave/employees/.

When applying through the state, please ensure that you search for your household employer by name. If you are unsure of your employer's name, please contact isohr@orionassoc.net
Select your role
Date of Communication

MonthDayYear
Date
Communication Method
Upload Written Communication

Cancelof
Employee Legal Name

Legal First NameLegal Last Name
Employee Email
example@example.com
Employee Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate the Participant that you work with and intend to take leave from and submit one form for each Participant.
Participant First Name

First NameLast Name
Type of Leave
Select the type of leave requested

Other
Anticipate Leave Start Date

MonthDayYear
Date
Anticipate Leave End Date

MonthDayYear
Date
Describe the family member or service member's relationship to the employee
Mother, father, sister, etc.
Comments
Supporting documentation (if applicable)

Cancelof
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Name of person filling out the form

Legal First NameLegal Last Name
Email of person filling out the form
example@example.com
Signature

Clear
Date of Signature

MonthDayYear
Date
Please verify that you are human
Should be Empty:

Orion ISO FS MN Paid Family Medical Leave

Type of Leave

Signatures