REQUEST FOR Please select
Anti-social Behaviour Act 2003 and Education Act 1996
Unauthorised Leave in Term Time or Failure to Return from Authorised Leave
Register Code G
This form is to be completed by the headteacher. Information contained in the form will be used in
legal action under Section 444 of the 1996 Act relating to non-attendance at school in the event that
a penalty notice is issued and remains unpaid.
I am writing to request that the Local Authority considers issuing a warning letter/penalty notice to the
parent(s) of the following pupil:
Pupil First Name
Pupil Surname
Post Code
Sex (M/F)
Unique Pupil No
Parent 1
Relationship to child
First Name
Post Code
Parent 2
Tel No
you MUST include details of all parents or explain why you have omitted this information
Relationship to child
First Name
Post Code
Tel No
The expression "parent", in relation to a child or young person, includes any person who is not a
parent of the child but who has parental responsibility for him or her, or who has care of the child. If
there are more than 2 parents please use an additional form.
Where details are completed for one parent only please explain below what attempt has been made
to obtain details for the second parent and why this has not been successful. It is not acceptable to
say that the parent is not known or not involved:
School Name
LCC School No
Contact Name
Tel No
Request for Warning Letter
Where the parent(s) have requested permission for leave during term-time (which has been
subsequently unauthorised) and they have given at least 2 weeks' notice before the leave start date,
a warning from the Court Officer must be issued.
Dates of intended leave
No Of Actual School Days
If the leave is still taken after a warning is issued, please resend this form, changing the title to request a
penalty notice and attach a copy of the SIMS/registration printout that shows the unauthorised absences.
Request for Penalty Notice
Warning letter already issued by court officer
If no warning letter was possible, please indicate why below
Warning letter not possible - Leave was taken without any notice
Warning letter not possible - Less than two weeks notice was given
Warning letter not possible - Failure to return from authorised leave
Attach a copy of the SIMs/registration printout which shows the unauthorised absence
In order for a request for a warning letter or penalty notice to be approved, you must
demonstrate why the absence has been or is to be marked as unauthorised leave.
This can be by one or more of the following:
Please indicate which evidence you have included with this application
Leave request forms
Letters to/from parents regarding the leave
Records of meetings or telephone calls to discuss the request
A brief report on the circumstances that led to the conclusion that the absence was leave
Failure to provide sufficient evidence may result in the application being rejected and/or
I can confirm that all our attendance registers are marked in respect of authorised or unauthorised
absence in accordance with the guidance issued by the Department for Education.
In making this request, I confirm that such action would not conflict with other intervention strategies
already in place or other enforcement measures already being processed. I can also confirm that the
governing body of this school has reviewed its attendance policy and agreed that this school will
request the Local Authority to issue Penalty Notices in appropriate cases.
I attach a SIMS/registration printout and have signed the declaration below regarding the
evidence contained therein for use in the issue of a Penalty Notice and where necessary, in any
legal action taken under Section 444 of the Education Act 1996.
I HEREBY CERTIFY that the particulars, on the attached SIMS/registration printout with respect
to the absences of the pupil named herein, are a true copy of the Register of this School, and
that the pupil was absent from this School on the dates shown.
Name (printed)
Please send this form, fully completed, to:
Court Officer (North), c/o Tracey Elrick, Directorate for Children & Young People, Lancashire County
Council, Fleetwood High School, Broadway, Fleetwood, Lancashire, FY7 8HE
For any enquiries about this form or penalty notices, please contact the court officer on the above address or
Revised August 2015