FORM F: Receipt of Maternity Benefit
[Rule 5(3)]
To
___________________ (name of mine or circus).
I, __________, the undersigned, a woman employee/ the nominee of ________ woman employee/ legal representative of woman employee deceased in _______ (name of mine or circus) at _______ in ________ district received maternity benefit and/or other amount due under the Maternity Benefit Act, 1961, from the employer of mine or circus referred to above, as detailed below:-
Rs.______ being the first installment of maternity benefit paid on _________ .
Rs.______ being the second installment of maternity benefit after delivery paid on _________
Rs.______ being the medical bonus under section 8 of the Act paid on _________
Rs.______ being the wages for the leave period from _____ to _____ mentioned under 2[section 9, 9A or 10].
*My/ Her confinement/ miscarriage 3[medical termination of pregnancy or tubectomy operation] took place on _______ or I/ she fell ill because of pregnancy, delivery, premature birth of a child or miscarriage 3[medical termination of pregnancy or tubectomy operation] on _____. In consequence I,_____ her nominee/ legal representative have received the aforesaid amounts prescribed in 1[sections 5, 8, 9, 9A and 10] of the Maternity Benefit Act, 1961.
Date ________ Signature or thumb impression of __________
*Woman employee or her nominee or legal representative
Signature of an attester in case the woman is not able to
Date ________ sign and affixes thumb impression
*Strike out unnecessary portion.
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