Maternity Benefit Act,1961
FORM E: Notice under Section 6 of the Maternity Benefit Act, 1961 for Proceeding on Maternity Leave
___________________ (name of mine or circus)
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
Signature of an Attester in case the woman is not able to sign and affix thumb impression.