Maternity Benefit Act, 1961
FORM H: Complaint
(Under the Maternity Benefit Act, 1961)
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 thereunder, 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 Attester in case the woman is unable to sign and affixes thumb impression. Full address of the woman.