FORM ‘I’ (See Rule 11) To The Inspector (Under the Maternity Benefit Act, 1961) Sir, I_________________(name), a person nominated under Section 6 by or legal representative of _______________________ (name of woman) employed in _____________ (name and full address of establishment) have to complain that the said woman having fulfilled the conditions laid down in the Maternity Benefit Act, 1961, and the rules thereunder is entitled to Rs.______________ being Maternity Benefit and/or Rs.__________________ being the medical bonus and/or Rs. _________________ being wages for leave due under Sections 9 and 10 but the same has been improperly withheld by the employer. He may, therefore, be directed to pay the aforesaid amount to me. Signature or thumb-impression of the Nominee/legal representative Dated____________ ----------
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