FORM ‘F’
(See Rule 6)
To
_______________________ (name of establishment)
I_______________ the undersigned, a woman employee/the nominee of
______________ woman employed/legal representative of __________________ woman
employee (deceased) in ________________________(name of establishment) at
_______________ in _______________ district received maternity benefit and/or the
other amount due under [the] Maternity Benefit Act, 1961, from the employer of the
establishment referred to above, as detailed below: -
Rs. ___________________ being the first installment of maternity
Benefit paid on ________________.
Rs. ___________________ being the second installment of maternity
Benefit after delivery paid on ___________.
Rs. ___________________ being the medical bonus under Section 8 of
the Act paid on ____________________.
Rs. ___________________ being the wages for the leave period from
__________ to ___________ mentioned under Sections
9 or 10.
*My/Her confinement/miscarriage took place on ______________ or I/She fell ill
because of pregnancy, delivery, premature birth of a child or miscarriage on
__________________. In consequence I __________________her nominee/legal
representative have received the aforesaid amounts prescribed in Section 5, 8, 9 and 10 of
the Maternity Benefit Act, 1961.
Signature or thumb impression______
*Woman employee or her nominee or
legal representative.
Signature of the attester.
Signature of the Competent Authority.
Date____________
*Strike out unnecessary portion.
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