Maternity Benefit (Mines and Circus) Rules, 1961 - Form F

FORM F
[See rule 5(3)]

FORM OF RECEIPT OF MATERNITY BENEFIT

To

……(name of ¹[mine or circus]). I,…., the undersigned, a woman employee/the nominee of….. woman employee/legal representative of…… woman employee deceased in……(name of ¹[mine or circus]) at…… in…… district received maternity benefit and/or other amount due under the Maternity Benefit Act, 1961, from the employer of ¹[mine or circus] referred to above, as detailed below:-

Rs…… being the first instalment of maternity benefit paid on…….
Rs…… being the second instalment 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 ¹[Medical termination of pregnancy or tubectomy operation] on. In consequence I,…… her nominee/legal representative have received the aforesaid amounts prescribed in ²[sections 5,8,9, 9A and 10] of the Maternity Benefit Act, 1961.

Signature or thumb impression of……..

*Woman employee or her nominee or legal representative

             Signature of an Attestor in case the woman is
               not able to sign and affixes thumb impression

Date…..

*Strike out unnecessary portion.