[First Name Last Name]

[Personal Address]

[Function]

[Recipient]

[Recipient Address]

[Commune] , on [date]

(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 family solidarity leave, provided for by Articles L3142-6 to L3142-13 of the Labor Code, to assist a relative at the end of life.

I wish to take this leave as of [date] in the form of [either a continuous period, a fractional period or part-time work (to be specified in each case)].

Attached to this application is the medical certificate attesting to the state of health of the person at the end of life whom I wish to assist.

Please accept my distinguished greetings.

Signature