Civil Service Form No.

6 ANNEX A
Revised 2020 Republic of the Philippines
City Government of Lucena
LCGC Diversion Road Brgy. Kanlurang Mayao, Lucena City

APPLICATION FOR LEAVE

3. DATE OF FILLING 4. POSITION 5.SALARY

6.DETAILS OF APPLICATION

6. A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE

Vacation Leave (Sec.51, Rule XVI, Omnibus Rules Implementing E.O No.292) In case of Vacation /Special Privilege Leave:
Mandatory/Forced Leave (Sec.51, Rule XVI, Omnibus Rules Implementing E.O No.292)
c Within the Philippines
Sick Leave (Sec.43, Rule XVI Omnibus Rules Implementing E.O No.292)
Maternity Leave (R.A No.11210/ IIR, issued by CSC, DOLE AND SSS) Abroad (Specify)

Paternity Leave (R.A No. 8187 CSC MC No. 71 s 1998, as amended) In case of sick leave:
Special Privilege Leave ((Sec 21, Rule XVI, Omnibus Rules Implementing E.O No.292)
In Hospital (Specify Illness)
Solo Parent Leave (RA No. 8972/CSC MC No.8 s 2004)
Study Leave (Sec.68, Rule XVI Omnibus Rules Implementing E.O No.292) Out Patient (Specify Illness)

10-Day VAWC Leave (RA No. 9262/CSC MC No.15 s 2005) In case of Special Leave Benefits Women:
Rehabilitation Privilege (Sec.55, Rule XVI Omnibus Rules Implementing E.O No.292) (Specify Illness)
Special Leave for Women (RA No. 9710/CSC MC No.25 s 2010)
Special Emergency (Calamity) Leave (CSC MC No. 2 s 2012 as amended)
Adoption Leave (R.A No. 8552) In case of Study Leave:

Completion of Master's Degree

Others: BAR/Board Examination Review

Other purpose:

Monetization of Leave Credits

Terminal Leave

6.NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION

________________________________________ Not Requested

INCLUSIVE DATES Requested

________________________________________ (Signature of Application)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION

As of _______________________ For approval

Vacation Leave Sick Leave For disapproval due to

Less this
application

Balance

(Authorized Officer)

(Authorized Officer)

7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:

_______ days with pay _______________________________________

_______ days without pay ___________________________________________

_______ others (Specify) ___________________________________________

(Authorized Official)
 INSTRUCTIONS AND REQUIREMENTS of the woman employee concerned.

TPO or PPO has been filed with the said office shall be
Application for any type of leave shall be made on this Form and sufficient to support the application for the ten-day leave;
to be accomplished at least in duplicate with documentary or
requirements, as follows: d. In the absence of the BPO/TPO/PPO or the certification, a
1.Vacation leave* police report specifying the details of the occurrence of
It shall be filed five (5) days in advance, whenever violence on the victim and a medical certificate may be
possible, of the effective date of such leave. Vacation Considered, at the discretion of the immediate
leave within in the Philippines or abroad shall be supervisor.
indicated in the form for purposes of securing travel of the woman employee concerned.
authority and completing clearance from money and work 10. Rehabilitation leave* – up to 6 months
accountabilities.  Application shall be made within one (1) week from the
2. Mandatory/Forced leave time of the accident except when a longer period is
Annual five-day vacation leave shall be forfeited if not warranted.
taken during the year. In case the scheduled leave has  Letter request supported by relevant reports such as
been cancelled in the exigency of the service by the head the police report, if any,
of agency, it shall no longer be deducted from the  Medical certificate on the nature of the injuries, the
accumulated vacation leave. Availment of one (1) day course of treatment involved, and the need to undergo
or more Vacation Leave (VL) shall be considered for rest, recuperation, and rehabilitation, as the case may be
complying the  Written concurrence of a government physician should be
mandatory/forced leave subject to the conditions under obtained relative to the recommendation for
Section 25, Rule XVI of the Omnibus Rules Implementing rehabilitation if the attending physician is a private
E.O. No. 292. practitioner, particularly on the duration of the period of
3. Sick leave* rehabilitation.
 It shall be filed immediately upon employee's return from 11. Special leave benefits for women* – up to 2 months
such leave.  The application may be filed in advance, that is, at least
 If filed in advance or exceeding five (5) days, five (5) days prior to the scheduled date of the
application shall be accompanied by a medical gynecological surgery that will be undergone by the
certificate. In case medical consultation was not availed employee. In case of emergency, the application for
of, an affidavit should be executed by an applicant special leave shall be filed immediately upon employee’s
4. Maternity leave* – 105 days return but during confinement the agency shall be
 Proof of pregnancy e.g. ultrasound, doctor’s certificate on notified of said surgery.
the  The application shall be accompanied by a medical
expected date of delivery certificate filled out by the proper medical authorities,
 Accomplished Notice of Allocation of Maternity Leave e.g. the attending surgeon accompanied by a clinical
Credits (CS Form No. 6a), if needed summary reflecting the gynecological disorder which
 Seconded female employees shall enjoy maternity leave shall be addressed or was addressed by the said
with full pay surgery; the histopathological report; the operative
5. Paternity leave – 7 days technique used for the surgery; the duration of the
Proof of child’s delivery e.g. birth certificate, medical surgery including the perioperative period (period of
certificate and marriage contract confinement around surgery); as well as the employees
6. Special Privilege leave – 3 days estimated period of recuperation for the same.
It shall be filed/approved for at least one (1) week prior to
availment,except on emergency cases. Special privilege 12. Special Emergency (Calamity) leave – up to 5 days
leave within the Philippines or abroad shall be indicated  The special emergency leave can be applied for a
in the form for purposes of securing travel authority maximum of five (5) straight working days or staggered
and completing clearance from money and work basis within thirty (30) days from the actual occurrence
accountabilities. of the natural calamity/disaster. Said privilege shall be
7. Solo Parent leave – 7 days enjoyed once a year, not in every instance of calamity
It shall be filed in advance or whenever possible five (5) or disaster.
days before going on such leave with updated Solo Parent  The head of office shall take full responsibility for the
Identification Card. grant of special emergency leave and verification of the
8. Study leave* – up to 6 months employee’s eligibility to be granted thereof. Said
 Shall meet the agency’s internal requirements, if any; verification shall include: validation of place of residence
 Contract between the agency head or authorized based on latest available records of the affected
representative and the employee concerned. employee; verification that the place of residence is
9. VAWC leave – 10 days covered in the declaration of calamity area by the proper
 It shall be filed in advance or immediately upon the government agency; and such other proofs as may be
woman employee’s return from such leave. necessary.
 It shall be accompanied by any of the following supporting
documents: 13. Monetization of leave credits
a. Barangay Protection Order (BPO) obtained from the Application for monetization of fifty percent (50%) or
barangay; more of the accumulated leave credits shall be
b. Temporary/Permanent Protection Order (TPO/PPO) accompanied by letter request to the head of the agency
obtained from the court; stating the valid and justifiable reasons.
c. If the protection order is not yet issued by the 14. Terminal leave*
barangay or the court, a certification issued by the Proof of employee’s resignation or retirement or
Punong Barangay/Kagawad or Prosecutor or the Clerk of separation
Court that the application for the BPO, from the service
15. Adoption Leave
 Application for adoption leave shall be filed with an
authenticated copy of the Pre-Adoptive Placement
Authority issued by the Department of Social Welfare and
Development (DSWD).

INSTRUCTIONS AND REQUIREMENTS