Application for Family Solidarity Leave in the Public Service (Model Document)
Continuous Leave
[First Name Last Name]
[Personal Address]
[Assignment Service]
[Grade]
[City] , on [date]
Attn. [appointing authority]
S/c [of the various intermediate hierarchical managers]
(Recommended letter with AR or hand delivery against discharge)
Subject: Request for family solidarity leave
[Lady] / [Sir] / [Quality] ,
I inform you of my intention to take a family solidarity leave, in order to assist [surname, first name, social security number, capacity (ascendant/descendant/brother/sister/person who shares the same home as the agent or who has designated him/her as a person of trust)] , which is at the end of its life.
Its social security fund is as follows: [skill]
I wish to take this leave as of [date] for a period of [duration up to 3 months] .
I also want to receive the daily support allowance for a person at the end of life, for a period of [indicate the number of payments desired, up to a limit of 21] .
(If several people share the daily allowance) I inform you that I will share the benefit of the daily allowance with [identity and status of any other beneficiary] .
Attached to this application is the doctor's certificate.
Please accept my distinguished greetings.
[Signature]
Split Leave
[First Name Last Name]
[Personal Address]
[Assignment Service]
[Grade]
[City] , on [date]
Attn. [appointing authority]
S/c [of the various intermediate hierarchical managers]
(Recommended letter with AR or hand delivery against discharge)
Subject: Request for family solidarity leave
[Lady] / [Sir] / [Quality] ,
I inform you of my intention to take a family solidarity leave, in order to assist [surname, first name, social security number, capacity (ascendant/descendant/brother/sister/person who shares the same home as the agent or who has designated him/her as a person of trust)] , which is at the end of its life.
Its social security fund is as follows: [skill]
I wish to take this leave as of [date] by periods of [days] consecutive days for a cumulative duration of [duration up to 6 months] according to the attached schedule.
I also want to receive the daily support allowance for a person at the end of life, for a period of [indicate the number of payments desired, up to a limit of 21] .
(If several people share the daily allowance) I inform you that I will share the benefit of the daily allowance with [identity and status of any other beneficiary] .
Attached to this application is the doctor's certificate.
Please accept my distinguished greetings.
[Signature]
Part-time
[First Name Last Name]
[Personal Address]
[Assignment Service]
[Grade]
[City] , on [date]
Attn. [appointing authority]
S/c [of the various intermediate hierarchical managers]
(Recommended letter with AR or hand delivery against discharge)
Subject: Request for family solidarity leave
[Lady] / [Sir] / [Quality] ,
I inform you of my intention to take a family solidarity leave, in order to assist [surname, first name, social security number, capacity (ascendant/descendant/brother/sister/person who shares the same home as the agent or who has designated him/her as a person of trust)] , which is at the end of its life.
Its social security fund is as follows: [skill]
I wish to take this leave as of [date] as part-time at [specify the desired work quantity] the [indicate the desired part-time days] for a period of [duration up to 3 months] .
I also want to receive the daily support allowance for a person at the end of life, for a period of [indicate the number of payments desired, up to a limit of 42] .
(If several people share the daily allowance) I inform you that I will share the benefit of the daily allowance with [identity and status of any other beneficiary] .
Attached to this application is the doctor's certificate.
Please accept my distinguished greetings.
[Signature]
Verified 14 February 2023 - Directorate for Legal and Administrative Information (Prime Minister)
For details, please use the practical information sheets :
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