Maternity Benefit Act,1961
FORM I: Complaint
(Under the Maternity Benefit Act, 1961)
I, ______ (name), a person nominated under section 6 by or a legal representative of _____ (name of woman) employed in ______ (name and full address of mine or circus) have to complain that the said woman having fulfilled the conditions laid down in the Maternity Benefit Act, 1961 and the Rules thereunder is 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] or 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 nominee/ legal representative
Date ________ Signature of an Attester in case the nominee/ legal representative is unable to sign and affixes thumb impression.
Full address of the nominee/legal representative.