FORM 'F' [See Rule 5 (3) ] Form of receipt of Maternity Benefit (Name of establishments). The undersigned, a woman*employee/the nominee of Woman employee/legal representative of Woman employee deceased in (name of Establishment) at in District received maternity benefit and/or other amount due under the Maternity Benefit Act, 1961, from the employer of the establishment 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 Sec. 9 or 10. *My/Her confinement/miscarriage took place on or I/She fell ill because of pregnancy, delivery, premature birth of child a miscarriage on ....... in consequence I her nominee/legal representative have received that aforesaid amounts prescribed in Section 5,8,9 and 10 of the Maternity Benefit Act, 1961. Signature or thumb impression of *Women employee or her nominee or legal representative, Signature of an attester in case the woman is not able to sign and affixes thumb impression. Date........... Strike out unnecessary portion.
