FORM ‘G’ (See Rule 10) To The Competent Authority Appointed under the Maternity Benefit Act, 1961. (ADDRESS) Sir, I_____________________, the undersigned, woman employee of _______________ (name of the establishment and full address) having been wrongly deprived by the employer of maternity benefit or medical bonus or both amounting to Rs._________(strike out unnecessary portion) for the reasons attached hereto, prefer this appeal under sub-section (2) of Section 12 and request that the said employer be ordered to pay the above mentioned amount to me. A copy of the order of the employer in this behalf is enclosed. Signature or thumb impression of the woman Dated______________ Signature of an Attester, in case the woman is not able to affix thumb-impression ---------------------
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