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Maternity Benefit (Mines and Circus) Rules, 1961

FORM I
[See rule 10]

To
The Inspector
(Under the Maternity Benefit Act, 1961)

I,….,(name), a person nominated under section 6 by or a legal representative of……(name of woman) employed in…….(name and full address of 1[mine or circus]) 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 2[section 9 or 9A] or 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 nominee
                                               /legal representative

Signature of an Attestor in case the nominee/legal
representative is unable to sign and affixes thumb impression.


Date…….                                        Full address of the nominee/
                                                      legal representative.

1.

Subs. by G.S.R. 59(E), dated 27th February, 1975 (w.e.f. 1-3-1975).

2.

Subs. by G.S.R. 70(E), dated 31st January, 1996 (w.e.f. 31-1-1996).

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