[See rule 10]
(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
Signature of an Attestor in case the nominee/legal
representative is unable to sign and affixes thumb impression.
Date……. Full address of the nominee/
Subs. by G.S.R. 59(E), dated 27th February, 1975 (w.e.f. 1-3-1975).
Subs. by G.S.R. 70(E), dated 31st January, 1996 (w.e.f. 31-1-1996).