FORM ‘B’
(See Rules 4 and 6)
Notice under Section 6 of the Maternity Benefit Act, 1961
(Name of the establishment)
1. ____________________(Name of the woman), wife/daughter of ___________
employed as __________________ at that I expect to be confined within six week next
following from the date of this notice/have given birth to a child____________(date) and
shall be absent from work from ______________(date).
I shall not work in any branch of establishment during the period for which I receive
maternity benefit.
2. For the purpose of Section 7, I hereby nominate _______________ (here enter name
and address of the nominee) to receive maternity benefit and/or any other amount due to
me under the Act, in case of my death.
3. That the maternity benefit due to me may be paid to me/my ________________
Shri/Shrimati_____________ whom I authorize to collect the same on my behalf.
Signature or thumb impression
of woman
Signature of an Attestor
Dated_________________
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