Form OF RECEIPT OF MATERNITY BENEFIT

I,……, the undersigned, a woman employee/ the nominee of…… woman employee or legal

representative of…… woman employee deceased in……(name of establishment) at…… in……

district received maternity benefit and/or other amount due under the Code on Social Security

,2020(36 of 2020) from the employer of the establishment referred to above, as detailed below:-

Rs…… being the first installment of maternity benefit paid on……

Rs…… being the second installment of maternity benefit after delivery paid on……

Rs…… being the medical bonus under section 64 of the Code paid on……

Rs……being the wages for the leave period from…… to…… mentioned under section 65.

*My/ Her confinement/ miscarriage or Medical termination of pregnancy or tubectomy operation

took place on…….or I/she fell ill because of pregnancy, delivery, premature birth of a child or

miscarriage or Medical termination of pregnancy or tubectomy operation on………… In consequence

I…… her nominee/legal representative has received the aforesaid amounts prescribed in sections 60,

64 and 65 of the Code on Social Security, 2020(36 of 2020).

Signature or thumb impression of………

*Woman employee or her nominee or legal representative

Signature of an Attester in case the woman is not able to sign

and affixes thumb impression

Place:

Date:

*Strike out unnecessary portion.