FORM F
[Rule 5(3)]
RECEIPT OF MATERNITY BENEFIT

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 instalment of maternity benefit paid on _________ .
Rs.______ being the second instalment 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 attestor in case the woman is not able to
Date ________ sign and affixes thumb impression
* Strike out unnecessary portion.
1. Substituted by GSR 64, dated 4th. February, 1992, w.e.f. 15th. February, 1992.
2. Substituted by GSR 70(E), dated 31st. January, 1996, w.e.f. 1st. February, 1996.
3.Inserted by GSR 70(E), dated 31st. January, 1996, w.e.f.1st. February, 1996.