Note for a Paid Family Leave claim, a few days at a time
A printable from Paid Family Leave Caregiving. Fill it in by hand. Nothing you write is collected by this website.
Note for a Paid Family Leave claim, a few days at a time
Attach this note to your DE 2501F.
My name: ____________________
Person I am caring for: ____________________ My relationship to them: ____________
I am taking intermittent family leave. I will keep working on some days.
| Day of the week | Will I work? (yes or no) | Hours I will work |
|---|---|---|
| Monday | ||
| Tuesday | ||
| Wednesday | ||
| Thursday | ||
| Friday | ||
| Saturday | ||
| Sunday |
My usual hours each week before leave: ______
Date I plan to return to my full schedule: ____________
Signature: ____________________ Date: ____________
Before you mail: answer Yes on question A13 and write your return date on question A12. Keep a copy.
From Paid Family Leave Caregiving. Facts checked October 21, 2026. Free information, not legal or medical advice.