Tip for Varies by state

States with paid family leave programs include: CA, CO, CT, DC, DE, MA, MD, ME, MN, NJ, NY, OR, RI, WA — check if your state has one

Tip for Varies by state

Paid family leave is separate from FMLA job protection — you may need to use both

Tip for Varies by state

File as early as possible to avoid gaps in income

Employment / FMLAmoderate

State Paid Family & Medical Leave (Generic)

Varies by state · Various State Agencies

Generic application for state-level paid family and medical leave programs. As of 2026, 13+ states plus DC have paid family and medical leave programs with their own application forms and certification requirements.

Form Details

Total fields: 36
Auto-fillable: 20 (56%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Apply through your state's paid leave program website

https://www.dol.gov/agencies/wb/featured-paid-leave

Each state has its own application process. Visit the DOL's paid leave page to find your state program.

📬

Mail to your state's paid leave agency

Check your state program website for the correct mailing address.

🏢

Visit your local state labor department office

Filing Deadline

Typically within 30 days of the start of leave. Check your state's specific deadline.

Required Attachments

📎 Medical certification from your healthcare provider (for medical leave)
📎 Documentation of qualifying event (birth certificate, adoption papers, military orders, etc.)
📎 Employer information and wage history
📎 State-specific claim forms (varies by program)

Processing Time

Typically 2-4 weeks from receipt of a complete application. Varies by state.

What Happens Next

Your state's paid leave program will review your application, verify eligibility, and begin benefit payments if approved. Benefits are typically 50-90% of average weekly wages, depending on the state.

Tips for This Form

✓ States with paid family leave programs include: CA, CO, CT, DC, DE, MA, MD, ME, MN, NJ, NY, OR, RI, WA — check if your state has one
✓ Paid family leave is separate from FMLA job protection — you may need to use both
✓ File as early as possible to avoid gaps in income
✓ Visit https://www.dol.gov/agencies/wb/featured-paid-leave to find your state's specific program

More Employment / FMLA Forms

FMLA Certification - Employee's Serious Health Condition

WH-380-E · U.S. Department of Labor

Certification of Health Care Provider for Employee's Serious Health Condition. Medical certification for FMLA leave for the employee's own condition.

FMLA Certification - Family Member's Serious Health Condition

WH-380-F · U.S. Department of Labor

Certification of Health Care Provider for Family Member's Serious Health Condition. Medical certification when employee needs leave to care for a family member.

FMLA Notice of Eligibility and Rights & Responsibilities

WH-381 · U.S. Department of Labor

Notice of Eligibility and Rights & Responsibilities. Employer must provide within 5 business days of FMLA leave request, stating whether employee is eligible.

FMLA Designation Notice

WH-382 · U.S. Department of Labor

Designation Notice. Employer designates leave as FMLA-qualifying or denies it. Must be provided within 5 business days of receiving sufficient certification.

FMLA Certification - Qualifying Exigency (Military)

WH-384 · U.S. Department of Labor

Certification of Qualifying Exigency for Military Family Leave. For leave due to a covered family member's active duty or call to active duty.

FMLA Certification - Serious Injury/Illness of Servicemember

WH-385 · U.S. Department of Labor

Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (current servicemember).

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Various State Agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.