Legal Intent to Return Form

LEGAL INTENT TO RETURN FORM

This Intent to Return Agreement (the "Agreement") is made as of Effective Date: by and between Employer Name: with principal address and Employee Name: .

RECITALS

WHEREAS, Employee has been on an approved leave of absence from employment with Employer for reasons described in Employee's leave documentation, and Employee desires to communicate a formal intention to return to active employment; and

WHEREAS, Employer has evaluated staffing needs and is willing to consider Employee's return subject to the conditions and qualifications set forth in this Agreement; and

WHEREAS, the parties wish to set forth, in writing, the mutual understandings and obligations relating to Employee's intended return to work.

NOW THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. INTENT TO RETURN

1.1 Employee hereby notifies Employer of Employee's intent to return to active employment on or about Return Date: . This statement of intent does not constitute a guarantee of position, promotion, or particular shift unless expressly agreed in writing by Employer.

2. POSITION, DUTIES AND SCHEDULE

2.1 Employee will perform duties consistent with the position above and will comply with all Employer policies, procedures and reasonable directives. Employer retains the right to assign or reassign duties consistent with business needs and applicable law.

3. CONDITIONS PRECEDENT

3.1 Employee's return is conditioned upon satisfaction of the following items, as applicable: medical clearance or fitness-for-duty certification, updated certifications or licenses, completion of required training, and verification of work authorization. Employer may withhold reinstatement until such conditions are satisfied.

3.2 If Employee is unable to satisfy the conditions listed above by the intended return date, the parties shall promptly confer regarding a revised return plan or reasonable accommodation where required by law.

4. COMPENSATION, BENEFITS AND REINSTATEMENT

4.1 Reinstatement of benefits, seniority, paid time off accrual and any other employment-related entitlements shall be governed by Employer's policies and applicable law. Where reinstatement is discretionary, Employer's decision shall be final subject to applicable statutory protections.

5. ACCOMMODATION AND RETURN-TO-WORK PROCESS

5.1 Employer and Employee agree to engage in an interactive process to evaluate reasonable accommodations necessary for Employee's return, if any, consistent with applicable law. Employee shall timely provide information reasonably requested to evaluate accommodation.

6. ACKNOWLEDGMENTS AND REPRESENTATIONS

6.1 Employee represents that the information provided to Employer regarding Employee's ability to return is true and complete to the best of Employee's knowledge. Employee acknowledges that submitting this Intent to Return Form is a representation of intent only and does not modify any employment-at-will relationship unless expressly set forth in a separate, written agreement signed by both parties.

7. CONFIDENTIALITY; RETURN OF PROPERTY

7.1 Employee shall continue to be bound by any confidentiality, non-disclosure, non-compete, or proprietary information obligations arising from prior agreements. Employee shall return all Employer property in Employee's possession prior to reinstatement unless otherwise authorized in writing.

8. NOTICES

8.1 All notices required or permitted under this Agreement must be in writing and delivered to the addresses below by hand delivery, certified mail (return receipt requested), or other method providing proof of delivery. Notices are effective upon receipt.

9. GOVERNING LAW; VENUE

9.1 This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to choice-of-law principles. The parties submit to the exclusive jurisdiction and venue of the state and federal courts located within that state for resolution of disputes arising under this Agreement.

10. ENTIRE AGREEMENT; SEVERABILITY

10.1 This Agreement constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous understandings, whether written or oral. 10.2 If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and the invalid or unenforceable provision shall be reformed to the extent necessary to make it valid and enforceable while preserving the parties' intent.

11. AMENDMENTS; WAIVER; COUNTERPARTS

11.1 This Agreement may be amended or modified only by a writing signed by both parties. 11.2 No waiver by either party of any breach or default shall be deemed a waiver of any subsequent breach or default. 11.3 This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

12. CERTIFICATION

Employee certifies that the information provided in this form is true and correct to the best of Employee's knowledge and that Employee will promptly notify Employer if circumstances affecting Employee's ability to return change prior to the actual return date.

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