Civil Service Form No.

6 Revised
2020
ANNEX A
Republic of the Philippines
LOCAL GOVERNMENT UNIT OF TALAKAG Stamp of Date of Receipt
Talakag, Bukidnon

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
MCRO BOCTOT JESSICA TINOY

3. DATE OF FILING November 22, 2021 4. POSITION Adm. Asst. 5. SALARY Php. 18,047.00

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) Mandatory/Forced In case of Vacation/Special Privilege Leave:

x (Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Sick Leave (Sec. 43, Rule XVI, Omnibus Rules
Leave Within the Philippines
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) Special Emergency (Calamity) In case of Study Leave:
Leave (CSC MC No. 2, s. 2012, as amended) Adoption Leave (R.A. No. 8552) Completion of Master's Degree BAR/Board
Examination Review
Others:
Other purpose:
Monetization of Leave Credits
Terminal Leave

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

1 day NotRequested
INCLUSIVE DATES Requested
DECEMBER 22, 2022
(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION For
As of approval
For disapproval due to
Vacation Leave Sick Leave
Total Earned
Less this application
Balance
BELEN BACARRISAS-CO
CECILIA M. LEDON (Authorized Officer)
HRMO V
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:
1 days with pay
days without pay
others (Specify)

VERGITO O. FACTURA
Municipal Mayor
 INSTRUCTIONS AND REQUIREMENTS
Application for any type of leave shall be made on this Form and to be TPO or PPO has been filed with the said office shall be sufficient to
accomplished at least in duplicate with documentary requirements, as support the application for the ten-day leave; or
follows: d. In the absence of the BPO/TPO/PPO or the certification, a police
report specifying the details of the occurrence of violence on the
1. Vacation leave* victim and a medical certificate may be considered, at the discretion
It shall be filed five (5) days in advance, whenever possible, of the effective of the immediate supervisor of the woman employee concerned.
date of such leave. Vacation leave within in the Philippines or abroad shall
be indicated in the form for purposes of securing travel authority and 10. Rehabilitation leave* – up to 6 months
completing clearance from money and work accountabilities.  Application shall be made within one (1) week from the time of the
accident except when a longer period is warranted.
2. Mandatory/Forced leave  Letter request supported by relevant reports such as the police report,
Annual five-day vacation leave shall be forfeited if not taken during the if any,
year. In case the scheduled leave has been cancelled in the exigency of
 Medical certificate on the nature of the injuries, the course of treatment
the service by the head of agency, it shall no longer be deducted from the
involved, and the need to undergo rest, recuperation, and
accumulated vacation leave. Availment of one (1) day or more Vacation
rehabilitation, as the case may be.
Leave (VL) shall be considered for complying the mandatory/forced leave
subject to the conditions under Section 25, Rule XVI of the Omnibus Rules  Written concurrence of a government physician should be obtained
Implementing E.O. No. 292. relative to the recommendation for rehabilitation if the attending
physician is a private practitioner, particularly on the duration of the
period of rehabilitation.
3. Sick leave*
 It shall be filed immediately upon employee's return from such leave. 11. Special leave benefits for women* – up to 2 months
 If filed in advance or exceeding five (5) days, application shall be  The application may be filed in advance, that is, at least five (5) days
accompanied by a medical certificate. In case medical consultation was
prior to the scheduled date of the gynecological surgery that will be
not availed of, an affidavit should be executed by an applicant.
undergone by the employee. In case of emergency, the application for
special leave shall be filed immediately upon employee’s return but
4. Maternity leave* – 105 days during confinement the agency shall be notified of said surgery.
 Proof of pregnancy e.g. ultrasound, doctor’s certificate on the expected  The application shall be accompanied by a medical certificate filled out
date of delivery by the proper medical authorities, e.g. the attending surgeon
 Accomplished Notice of Allocation of Maternity Leave Credits (CS Form accompanied by a clinical summary reflecting the gynecological
No. 6a), if needed disorder which shall be addressed or was addressed by the said
 Seconded female employees shall enjoy maternity leave with full pay in surgery; the histopathological report; the operative technique used for
the recipient agency. the surgery; the duration of the surgery including the peri- operative
period (period of confinement around surgery); as well as the
5. Paternity leave – 7 days employees estimated period of recuperation for the same.
Proof of child’s delivery e.g. birth certificate, medical certificate and
marriage contract 12. Special Emergency (Calamity) leave – up to 5 days
 The special emergency leave can be applied for a maximum of five
6. Special Privilege leave – 3 days (5) straight working days or staggered basis within thirty (30) days from
It shall be filed/approved for at least one (1) week prior to availment, except the actual occurrence of the natural calamity/disaster. Said privilege
on emergency cases. Special privilege leave within the Philippines or shall be enjoyed once a year, not in every instance of calamity or
abroad shall be indicated in the form for purposes of securing travel disaster.
authority and completing clearance from money and work accountabilities.  The head of office shall take full responsibility for the grant of special
emergency leave and verification of the employee’s eligibility to be
7. Solo Parent leave – 7 days granted thereof. Said verification shall include: validation of place of
It shall be filed in advance or whenever possible five (5) days before going residence based on latest available records of the affected employee;
on such leave with updated Solo Parent Identification Card. verification that the place of residence is covered in the declaration of
calamity area by the proper government agency; and such other proofs
8. Study leave* – up to 6 months as may be necessary.
 Shall meet the agency’s internal requirements, if any;
 Contract between the agency head or authorized representative and the 13. Monetization of leave credits
employee concerned. Application for monetization of fifty percent (50%) or more of the
accumulated leave credits shall be accompanied by letter request to the
9. VAWC leave – 10 days head of the agency stating the valid and justifiable reasons.
 It shall be filed in advance or immediately upon the woman employee’s
return from such leave. 14. Terminal leave*
 It shall be accompanied by any of the following supporting 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 court, a  Application for adoption leave shall be filed with an authenticated copy
certification issued by the Punong Barangay/Kagawad or Prosecutor of the Pre-Adoptive Placement Authority issued by the Department of
or the Clerk of Court that the application for the BPO, 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. 1985).