Civil Service Form No.

6 Revised 2020 Republic of the Philippines

(Agency Name) LEAVE
(Agency Address)
ANNEX A

APPLICATION FOR Stamp of Date of Receipt

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

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. Within the Philippines __________________________
292) Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify) ______________________________ In
Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) 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. Out Patient (Specify Illness) _____________________
292) 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) Leave (CSC MC No. 2, s. 2012, as

In case of Study Leave:

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

________________________________________ Not Requested
INCLUSIVE DATES Requested
________________________________________
(Signature of Applicant)

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