Civil Service Form No.

6
Revised 2020

Republic of the Philippines

LOCAL GOVERNMENT UNIT Stamp of Date of Receipt
Libon, Albay

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)

MYDO / SIKAP RAGODON JACK JR SEGUI

APRIL 4, 2022 MYDO I 19,085.00

3. DATE OF FILING ______________ 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. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Within the Philippines MANILA, PHILIPPINES
_____________________________
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify)
Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) In case of Sick Leave:
_____________________
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) In Hospital (Specify Illness)
____________________
Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Out Patient (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)
In case of Special Leave Benefits for Women:
________________________________
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005)
(Specify Illness)
_____________________________________________
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010)
In case of Study Leave:
Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended)
Completion of Master's Degree
Adoption Leave (R.A. No. 8552)
BAR/Board Examination Review
Other purpose:
Others:
_____________________________________ Monetization of Leave Credits

6.C NUMBER OF WORKING DAYS APPLIED FOR Terminal Leave

6.D COMMUTATION
3 WORKING DAYS
__________________ Not Requested
INCLUSIVE DATES Requested
APRIL 6 - 8, 2022
____________________________
(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION

As o f _______________________ For approval
Vacation Leave Sick Leave For disapproval due to ________________________
Total Earned ___________________________________________
Less this application ___________________________________________
Balance ___________________________________________

___________________________________________
MARITES R. PALEVINO

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

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________

WILFREDO V. MARONILLA
Municipal Mayor
_________________________________
 INSTRUCTIONS AND REQUIREMENTS

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

* For leave of absence for thirty (30) calendar days or more and terminal leave, application shall be accompanied by a clearance from money, property and work-related accountabilities (pursuant to CSC Memorandum Circular No. 2, s.