FORM ‘I’
(See Rule 11)
To
The Inspector
(Under the Maternity Benefit Act, 1961)
Sir,
I_________________(name), a person nominated under Section 6 by or legal
representative of _______________________ (name of woman) employed in
_____________ (name and full address of establishment) 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 Sections 9 and 10 but the same has been improperly withheld
by the employer. He may, therefore, be directed to pay the aforesaid amount to me.
Signature or thumb-impression of the
Nominee/legal representative
Dated____________
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