FORM ‘H’
(See Rule 11)
To
The Inspector
(Under the Maternity Benefit Act, 1961)
Sir,
I _________________ (name of the woman) employed in ________________(name and
full address of the establishment) having fulfilled the conditions laid down in the
Maternity Benefit Act, 1961 and the Rules thereunder, am entitled to Rs.___________
being maternity benefit *and/or Rs. ____________ being the medical bonus and/or Rs.
______________ being wages for leave due under Section 9 or 10 but the same has been
improperly withheld by the employer. He may, therefore, be directed to pay the aforesaid
amount to me.
Signature of thumb impression
of the woman
Full address_________________
Dated____________________
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