FORM 1

[See rule 3]

Notice under section 6 of the maternity Benefit Act of 1961

To,

………………………………………………………………………………………………………………
(Name of employer)

I,………………………………… (Name of woman)*wife/*daughter of ……………………………employed

as …………………….. at ……………………………………hereby give you notice that I* expect to be confined

within six weeks from the date of this notice and shall be absent from work from ……………………….. /

*have given birth to a child on ……………………………….. .

The maternity benefit and any other amount to which I am entitled under the provisions of the Maternity Benefit

Act, 1961, may be paid to ……………………………………………………………*Me/*Shri/Shrimathi/Kumari.

I shall not work in any establishment during the period for which I receive maternity benefit.

Date………………………………………………….

Signature of an attestor in case the woman is Signature or Thumb impression

Not able to sign, and affixes thumb impression of woman

* To be struck off when not applicable

 FORM 2
[See rule 5 (1)]

This is to certify that I examined…………………………………………………………………*wife/* daughter

of ……………………. A woman employed in ………………………………on ……………………………and.

*found that she is pregnant and is expected to be delivered of a child within ………………………………………

(mention months and days) from the above-mentioned date / * found that she is delivered of a child on ………….

…………………………………… /* found that she had miscarriage on …………………………………………./

found that she is suffering from …………………………………….. ………….……..an illness arising out of her

*pregnancy / *delivery / *premature birth of a child / *miscarriage.

Date……………………….. Signature, qualifications and designation

if any, of registered medical practitioner.

Note. - The expressions “child” and “miscarriage” are defined in the Act as follows:-

(1) “ Child” includes a still-born child;

(2) “Miscarriage” means expulsion of the contents of a pregnant uterus at any period prior to or during
the twenty-sixth week of pregnancy but shall not include any miscarriage, causing of which is punishable under
the Indian Penal Code (45 of 1880).

* To be struck off when not applicable

 FORM 3
[See rule 8(1)]

This is to certify that I examined ………………………………*wife/*daughter of……………….........................

a woman employed in ………………………………………………...and found that * she has been delivered of a

child on ………………………………………./ *she had miscarriage on ……………………………………… .

Date……………………………….. Signature of a registered midwife.

Note. - The expressions “child” and “miscarriage” are defined in the Act as follows:-

(1) “ Child” includes a still-born child;

(2) “Miscarriage” means expulsion of the contents of a pregnant uterus at any period prior to or during
the twenty-sixth week of pregnancy but shall not include any miscarriage, causing of which is punishable under
the Indian Penal Code (45 of 1880).

* To be struck off when not applicable