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Requires associate identification, contact information, address, leave dates (including intermittent leave), and adoption-related caregiving details when applicable. Includes compliance statements confirming receipt and understanding of relevant notices and benefits, authorization for payroll deductions, awareness of submission deadlines, and acknowledgment of return-to-work obligations and potential consequences. Includes associate signature and date fields.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/si20-leave-of-absence-application-form/181521/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/si20-leave-of-absence-application-form/181521.png","ImageObject",300,407,{"name":92,"@type":93},"Ethan Miller","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-02",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",16,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What information must be completed in Section A of the LOA application?","Question",{"text":113,"@type":114},"The form collects associate name and ID, contact details, current home address, leave request dates, and whether leave is intermittent. 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Yes  No |  |  |  |  |  |  |  |  |\n| If so, please provide the dates of service:   |  |  |  |  |  |  |  |  |\n| Associate’s Current Home Street Address: | City: |  |  |  |  | State | Zip |  |\n| Leave Request (e.g. 01/31/2021) | Last Day Worked |  |  |  |  | Intermittent Leave? |  |  |\n| From / / To / / | / / |  |  |  |  |  Yes  No |  |  |\n| If the leave is for child care of an adopted child – please complete: |  |  |  |  |  |  |  |  |\n| Estimated date of adoption: / / |  |  |  |  |  |  |  |  |\n| Are you the primary care giver?  Yes  No Does the child’s other parent work for ADP?  Yes  No |  |  |  |  |  |  |  |  |\n| If the other parent works for ADP and will be taking an adoption leave, enter the other parent’s name: |  |  |  |  |  |  |  |  |\n| If you are requesting a Personal Leave-please have your HRBP or manager provide: |  |  |  |  |  |  |  |  |\n| Accrual Balance for: Float Time:   Vacation Time:   |  |  |  |  |  |  |  |  |\n| Workplace Injury: |  |  |  |  |  |  |  |  |\n| Please note: If you have been injured on the job and would like to initiate a Workers Compensation claim, you must immediately contact the HRPRCat 1-877-237-4711 and complete a separate form called the ‘First Report of Injury’. |  |  |  |  |  |  |  |  |\n| For all leave requests, please check or initial the following: |  |  |  |  |  |  |  |  |\n|  I have received and read the Family and Medical Leave Act Notice included in the packet of information. |  |  |  |  |  |  |  |  |\n|  I have read the Leave of Absence Benefit package specific to my leave. |  |  |  |  |  |  |  |  |\n|  I understand a Medical Release to Return to Work Form that, if applicable, includes job restrictions / requests for accommodations must be |  |  |  |  |  |  |  |  |\n| completed and submitted to the ADP Leave Administrator prior to my return to active work. |  |  |  |  |  |  |  |  |\n|  I authorize payroll deductions from my pay and, if necessary, agree to execute a repayment agreement as such time, for any overpayment |  |  |  |  |  |  |  |  |\n|  I received while out on leave. |  |  |  |  |  |  |  |  |\n|  I understand I have 30 days to submit FMLA forms for review. |  |  |  |  |  |  |  |  |\n|  I understand failure to return to work or to keep my manager informed of my return to work may constitute job abandonment and lead to |  |  |  |  |  |  |  |  |\n| termination of my employment with ADP. |  |  |  |  |  |  |  |  |\n|  I understand that my failure to complete any of the required forms within the specified time frames above may result in the discontinuation |  |  |  |  |  |  |  |  |\n| of my pay and may impact my continued employment. |  |  |  |  |  |  |  |  |\n|  I understand that, if granted a leave, I may not seek or engage in gainful employment elsewhere (unless I have been called to active duty |  |  |  |  |  |  |  |  |\n| service if the U.S. Military. |  |  |  |  |  |  |  |  |\n| (For FMLA ONLY) I hereby authorize my health care provider to complete a Certification of Health Care Provider (Family and Medical Leave Act 1993) and submit the certification to the ADP Leave Administrator in order to determine whether my absences are qualified under FMLA of |  |  |  | ","cbCaitoWX2wqui7U","https://ap.wps.com/l/cbCaitoWX2wqui7U","pdf",133794,"English","# Section A: LOA APPLICATION – ASSOCIATES SECTION\n## To Be Completed by Associates for All Leave Reasons\n## Associate Signature and Date","[{\"question\":\"What information must be completed in Section A of the LOA application?\",\"answer\":\"The form collects associate name and ID, contact details, current home address, leave request dates, and whether leave is intermittent. It also includes additional fields depending on the leave reason, such as adoption caregiving information for adoption requests.\"},{\"question\":\"What deadlines and compliance requirements are stated for FMLA forms?\",\"answer\":\"The form states that associates have 30 days to submit FMLA forms for review. It also warns that failure to complete required forms within the specified time frames may result in discontinuation of pay and impact continued employment.\"},{\"question\":\"What happens if an associate does not return to work as required?\",\"answer\":\"The form explains that failure to return to work or to keep the manager informed of the return may constitute job abandonment and lead to termination. It also notes that returning may require a Medical Release to Return to Work form if applicable.\"}]","SI.20 - Leave of Absence Application Form | PDF"]