[See rule 9]
The Competent Authority
(Appointed under the Maternity Benefit Act, 1961).
I,…, the undersigned, woman employee of…..(name and full address 1[mine or circus]) have been wrongly deprived by the employer of maternity benefit or medical bonus or both (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.
Date……. Signature or
thumb impression of the woman
Signature of an Attestor in case the woman is
not able to sign and affixes thumb impression.
Full address of the nominee/legal representative
Subs. by G.S.R. 59(E), dated 27th February, 1975 (w.e.f. 1-3-1975).