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Sample Flexible Working Request

A worked statutory flexible-working request setting out the proposed pattern, start date, business reasons and consultation approach.

Jurisdiction: Illustrative England and Wales example — mandatory statutory, regulatory and professional requirements must be checked

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Important: This sample provides general legal information only and is not legal advice. Check the law, prescribed forms and signing requirements that apply to your exact jurisdiction and circumstances before use.

# EXAMPLE: FLEXIBLE WORKING REQUEST

Date: 19 May 2027

From: Amelia Frost

To: the other party named in this worked example

## 1. Purpose and status

This is a completed fictional a statutory request to work compressed hours and two home-working days. It records the issuer's decision or request and is not legal advice. The recipient should check the facts, contractual terms and any statutory procedure before relying on it.

## 2. Facts and evidence

Amelia makes a statutory flexible-working request dated 19 May 2027 under the Employment Rights Act 1996.

The issuer considered the documents, dates and explanations reasonably available and has kept a clear record. No conclusion is intended to prevent a right to respond, appeal or request a reasonable adjustment.

## 3. Decision or request

From 1 September 2027 she asks to work compressed hours Monday to Thursday, with Tuesdays and Thursdays from home, while keeping her 9.30 am to 3.00 pm availability.

The reason is childcare for her daughter and reduced commuting time; she proposes a three-month trial with measurable service-level checks.

## 4. Rights and next steps

The employer must consult in good faith, consider the statutory refusal grounds and give a decision within the applicable decision period. This request does not itself vary the contract.

Any response must be in writing to the named issuer within the period stated above. A worker may be accompanied where the applicable procedure permits, and statutory rights under the Employment Rights Act 1996, Equality Act 2010, family-leave rules and the ACAS Code are not excluded.

## 5. Confidentiality and records

The letter is confidential, stored securely and shared only with people who need it for the employment process, legal advice or a lawful reporting duty. Personal data is handled under UK GDPR. The issuer will correct a material factual error and keep a proportionate audit trail.

## 6. Closing

This letter does not vary a contract unless it expressly says so and is accepted in the legally required form. Nothing limits whistleblowing, discrimination, maternity or other protected rights.

Yours sincerely,

Harriet Cole, for the issuer

Signature: ______________________________

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