[See rule 10]
(Under the Maternity Benefit Act, 1961)
I…… (name of woman) employed in…… (name and full address of 2[mine or circus]) 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 1[section 9or 9A] 10 but the same has been improperly withheld by the employer. He may, therefore, be directed to pay the amount to me.
Date…… Signature or
thumb impression of the woman
Signature of an Attestor in case the woman
is unable to sign and affixes thumb impression.
Date…… Full address of the woman.
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