SSS Paternity Leave Form

Below are samples of Paternity leave Form

1. In the Philippines

Ateneo de Manila University
Human Resource Management Office


Employee Name: __________________________________________

Position Title / Rank:___________________Unit / Dept: ___________
Personnel Category:[ ]Faculty [ ]Staff [ ]Professional [ ]Admin. Officer

Wife's Name:   First Name   ______________Maiden Name  ________

Home Address:  ___________________________________________

This is to notify my employer that my wife is pregnant and is expected
to give  birth on (due date) ___________________________.This will
be her [ ] first   [ ] second   [ ] third   [ ] fourth  [ ] _______
delivery (counting all childbirths and miscarriages).

As supporting document(s). I have attached:
[ ]  photocopy of marriage contract (only for the Initial Notification)
[ ]  physician's certification as to expected date of delivery

I certify on my honor that the foregoing information is true and correct,
and that I am providing such information for the purpose of securing
eligibility for Paternity Leave Benefit as provided under R.A. No.8187.

______________________                 ____________________
        Signature of Employee                          Date

Endorsed by:

Noted by:
                               Unit Head

Here is the link to the original paternity leave form

2. In the United States of America

From: James Hadley
      Arthur Road, California

To: The Mather and Andrews Lawyers and Solicitors,
    Rosewood Building, Park Street, California

21st June 2010

Ref: Application for paternity leave

Dear Sir,

I am forwarding my application for paternity leave as you are well
aware that my wife has delivered a baby last night. There is no one
to look after my 3 year old daughter at home. I will find it
difficult to manage home and office. Since my wife has had a cesarean
section as her labor was difficult she will have to stay in the
hospital for a week.

Besides this the baby has developed jaundice. Although the doctors
say that it is not a cause to worry, my wife will get a discharge
only after the baby is normal.

Sir, I therefore request you to kindly grant me a month’s paternity
leave w.e.f. 22nd June, 2010.

Thanking you,


James Hadley

Here is the link to the original paternity leave form sample

Your name

Your Address

Your City state, zip

Your Phone number,

Your Email





Office address,

City, State, Zip.

Dear sir,

I am writing this letter to inform you that my wife is in her last
stages of pregnancy with our first child and I wish to take two weeks
of paternity leave and another two weeks for unplanned leave as no
one is around her to take care of her and the child. I would avail
this leave after the delivery and as this is the first child I cannot
provide you with accurate leave dates.

I will take 4 weeks of leave till my parents are around to take
care of her and child.

I hope you understand my position and allow me to avail these leaves.
I will resume work after a month as soon as my parents are in and
join work immediately.

Thank you for your time and consideration.


Your Name

Here is the link to the original paternity leave form sample

John P. Jacobs, Senior Assistant
Smith Communications
854 Bluebird Lane
Columbus, OH 43266

April 11, 2014

Marcy Osedo, HR Manager
Smith Communications
9332 Red Rock Road
Columbus, OH 43266

Dear Ms. Osedo,

As you may already be aware, my wife and I are happy to be expecting
our first child, due to be born in June. I am writing this letter to
request a paternity leave of 4 weeks in order to care for my family,
starting 8 weeks from now on May 26, 2014, until June 23, 2014. At
the end of the 4 weeks, I will return to the office and resume my
work normally.

I will endeavor to complete all currently unfinished projects between
now and May 26, and put forth as much effort as possible into making
up for lost time when I return to the office at the end of my
paternity leave. I can be reached during my leave if any clarification
is needed in this matter. If you have any questions or concerns,
please do not hesitate to leave a message for me via telephone at
(332)987-3922 or by email at john@jacobs.com and I will get in
touch with you as soon as possible.

I appreciate your assistance in this matter, as a paternity leave
will enable me to help my family transition into its new stage in
a healthier way and allow me to be more focused on my projects
when I do come back to work. Thank you for your consideration.

Yours sincerely,

John P. Jacobs
Senior Assistant

Here is the link to the original paternity leave form sample

3. In the UK

   Sample Paternity Leave Form - UK
   Sample Leave Appication Form

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