Form ML1
Application for maternity leave and pay
Please read our Maternity leave and pay policy before you complete this form.
Your details
Name
Title
Job title
Home address
Postcode
Work phone
Home phone
(Please inform your Line Manager if your home address changes during your maternity
leave.)
Which maternity scheme applies to you?
Please indicate the scheme which applies to you (eligibility is explained within our Maternity and Pay
policy)
1
University of York Occupational Maternity Scheme
• 39 weeks paid leave (18 weeks leave on full pay and 21 weeks on
Statutory Maternity Pay)
• 13 weeks’ unpaid leave
2
Ordinary Maternity Leave with Statutory Maternity Pay
• 39 weeks on Statutory Maternity Pay
• 13 weeks’ unpaid leave
3
Ordinary Maternity Leave with Maternity Allowance
• 39 weeks leave on Maternity Allowance
• 13 weeks’ unpaid leave
(Please note that Maternity Allowance is paid by Jobcentre Plus, not the
University)
Key dates
1. Expected week of childbirth (EWC): week beginning Sunday
2. 15th week before EWC: week beginning Sunday
3. Maternity Leave expected to commence:
4. Dates of paid annual leave to be taken before maternity leave by agreement with the
Line manager:
from:
to :
5. Dates of paid annual leave to be taken immediately after maternity leave by agreement
with the Line manager:
from:
to :
6. Anticipated date of return to work:
Further details
Please tick the following as applicable:
I confirm that I am pregnant and wish to apply for any benefits to which I may be
entitled.
I require further information regarding my superannuation contributions during
my maternity leave period.
I intend to be absent for up to 39 weeks and will give at least 8 weeks’ notice in
writing if I intend to return to work before the 39 weeks are up.
I intend to be absent for 52 weeks (i.e. 26 weeks’ Ordinary Maternity Leave plus
26 weeks’ Additional Maternity Leave).
I intend to be absent for up to 52 weeks (i.e. 26 weeks’ Ordinary Maternity
Leave plus up to 26 weeks’ Additional Maternity Leave) and will give at least 8
weeks’ notice in writing if I intend to return to work before the 52 weeks are up.
I intend to return to work following my maternity leave.
I am unsure at this time as to whether or not I will return to work following my
maternity leave; therefore I wish to postpone payment of the appropriate part of
my Occupational Maternity Pay until I have actually returned to work for the
required period of time.
I will not be returning to work after my maternity leave.
Declaration
I have read and understood the University’s Maternity and pay policy and I agree to the
following:
a) I will respond within the required timescales to all University correspondence regarding
my maternity leave or I may, subject to my contract of employment, forfeit my right to
return to work.
b) I understand that failure to return to work for the required period of time following my
maternity leave may result in the repayment of all or some of the Occupational Maternity
Pay I have received. I undertake to refund to the University any monies paid in excess of
SMP and confirm that any outstanding monies may be deducted from my final
salary/wage payment.
Signed
Date
What to do next

Return this form to your Line manager as soon as possible

If you already have your maternity certificate (Mat B1), please enclose it with this form. If
it is not available at this stage, send it to your line manager as soon as it is available. All
details of your maternity leave and, if applicable, pay will be confirmed in writing by your
line manager shortly thereafter.

Please contact your line manager as soon as possible should your anticipated dates
change.