Maternity Benefit Act,1961

FORM F: Receipt of Maternity Benefit

[Rule 5(3)]

To

___________________ (name of mine or circus).

I, __________, the undersigned, a woman employee/ the nominee of ________ woman employee/ legal representative of woman employee deceased in _______ (name of mine or circus) at _______ in ________ district received maternity benefit and/or other amount due under the Maternity Benefit Act, 1961, from the employer of mine or circus 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 ²[section 9, 9A or 10].

*My/ Her confinement/ miscarriage ³[medical termination of pregnancy or tubectomy operation] took place on _______ or I/ she fell ill because of pregnancy, delivery, premature birth of a child or miscarriage ³[medical termination of pregnancy or tubectomy operation] on _____. In consequence I,_____ her nominee/ legal representative have received the aforesaid amounts prescribed in ¹[sections 5, 8, 9, 9A and 10] of the Maternity Benefit Act, 1961.

Date ________ Signature or thumb impression of __________

*Woman employee or her nominee or legal representative

Signature of an attester in case the woman is not able to

Date ________ sign and affixes thumb impression

*Strike out unnecessary portion.

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