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Maternity Leave Application
This form is to be used for employees to tell us that you are going to go on maternity leave.
PART 1 – APPLICATION FOR LEAVE
To be completed by the employee
Section A – Personal Details These questions must all be answered. Your personal reference number can be found on your payslip.
1. Surname
2. Forenames
3. Payroll Number
4. Position Held
Section B – Contact details
6. Home / personal address
7. Work phone no.
8. Email address
Section C – Details of leave Please enclose the MATB1 form, which your midwife or GP will have given to you. The expected leave date (question 10) can be, at earliest, the start (Sunday) of the eleventh week prior to the expected week of confinement.
9. Expected
birth date
10. Expected date of
start of leave
If your plans to return to work following maternity leave are still provisional you may opt to be paid Statutory Maternity Pay / Maternity Allowance only during your maternity leave to avoid the possibility of repayment of money in excess of this later. If you do return to work for at least three months you will receive the balance of occupational maternity pay owing to you.
11. Do you wish to be paid SMP / Maternity Allowance only?
Yes – only SMP / MA
No – please pay occupational
maternity pay too
Section D – Working Pattern We need to know what days of the week you are working in order that we can calculate your leave entitlement correctly. In question 13, tell us the start date of this pattern (even if in the past). If your pattern changes before you go on leave, you must tell us.
12. Working pattern
Every weekday Monday-Friday
Specified below
Mon
Tue
Wed
Thu
Fri
Sat
Sun
13. Start date of this
pattern (if known)
Please sign overleaf…
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Section E – Declaration
I apply for maternity leave, as set out above. Should I not return to work after my maternity leave or return for a period of less than three months, I agree to repay the Parish Council any pay I have received in excess of the Statutory Maternity Pay / Maternity Allowance in force at that time.
Signed Date
This form should now be sent to the Parish Administrator.
PART 2 – INSTITUTIONAL ACKNOWLEDGEMENT
To be completed by the institution
The original form MATB1 is attached and I have retained a copy of it for my own records.
Signed Name
Position Date
Telephone
This form should now be sent to the Parish Administrator.
PART 3 – FOR HR USE
To be completed by the HR Division If the answer to 14 is “No”, issue an SMP1 form and state the reason in question 16.
14. Employee qualifies for SMP
Yes
No
15. Latest return date
16. Comments
Signed Name
Position Date
