FORM E: Notice under Section 6 of the Maternity Benefit Act, 1961 for Proceeding on Maternity Leave

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[Rule 5(1)]

To

___________________ (name of mine or circus)

I _________ (name of woman) wife/ daughter of ___________ employed as _______ at ______ (name of mine or circus), hereby give notice that I expect to be confined within six weeks next following from the date of this notice/have given birth to a child on _____ (date) and shall be absent from work from _______ (date). I shall not work in any establishment during the period for which I receive maternity benefit.

2. For the purpose of section 7, I hereby nominate ______ (here enter name and address of the nominee) to receive maternity benefit and/ or any other amount due to me under the Act in case of my death.

Signature of thumb impression of woman

Date _____________

Signature of an Attester in case the woman is not able to sign and affix thumb impression.

 

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