Employee request for bereavement (funeral/mourning) leave following the death of a family member or other qualifying individual. Captures relationship to the deceased, leave dates, and acknowledgment of company policy.
The Bereavement Leave Request is a ready-to-use employment & hr template you can send for signature in minutes. It is written for 1 signer (employee) and, by default, expires 30 days after it is sent if left unsigned. It covers bereavement, funeral leave, mourning leave, leave request, hr, employment. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Bereavement Leave Request This form documents an employee's request for bereavement leave following the death of a family member or other qualifying individual. It is submitted to Human Resources and the employee's direct manager for review. --- ## Part A — Employee Information **Full Legal Name:** ___________ **Employee ID / Personnel Number:** ___________ **Department:** ___________ **Job Title:** ___________ **Manager / Supervisor Name:** ___________ **Work Email:** ___________ **Work Phone:** ___________ **Date of Hire:** ___________ --- ## Part B — Information About the Deceased **Name of the Deceased:** ___________ **Date of Death:** ___________ **Relationship of the Deceased to You:** ___________ **If "Other," describe the relationship:** ___________ **Location of Memorial Services / Funeral (City, State):** ___________