FORM H
[Rule 10]
COMPLAINT

To
       The Inspector,
       (Under the Maternity Benefit Act, 1961)
Sir,
I ______ (name of woman) employed in _________ (name and full address of 3[mine or circus]) having fulfilled the conditions laid down in the Maternity Benefit Act, 1961 and the Rules there under, am entitled to Rs. ______ being maternity benefit and/or Rs. ____ being the medical bonus and/or Rs. ____ being wages for leave due under 2[section 9 or 9A] 10 but the same has been improperly withheld by the employer. He may, therefore, be directed to pay the amount to me.
Date _________ Signature or thumb impression of the woman.
Date ________ Signature of an Attestor in case the woman is unable to sign and affixes thumb impression. Full address of the woman.
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.