FORM ‘B’ (See Rules 4 and 6) Notice under Section 6 of the Maternity Benefit Act, 1961 (Name of the establishment) 1. ____________________(Name of the woman), wife/daughter of ___________ employed as __________________ at that I expect to be confined within six week next following from the date of this notice/have given birth to a child____________(date) and shall be absent from work from ______________(date). I shall not work in any branch of 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. 3. That the maternity benefit due to me may be paid to me/my ________________ Shri/Shrimati_____________ whom I authorize to collect the same on my behalf. Signature or thumb impression of woman Signature of an Attestor Dated_________________
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