FORM E
[Rule 5(1)]
NOTICE UNDER SECTION 6 OF THE MATERNITY BENEFIT ACT, 1961 FOR PROCEEDING ON MATERNITY LEAVE

To
 ___________________ (name of mine or circus)
1. 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 Attestor in case the woman is not able to sign and affix thumb impression.