Form IX

[See Sub-Rule (2) (a) and (c) of Rule-22]

(Notice of Claim for Maternity Benefit and Payment thereof under section 62 &

63)

To

……………….… (name of establishment)

PART I

Notice

[See Rule 22 (2) (a)]

I …………. (name of woman) wife/ daughter of…… employed as…… at………

(name of establishment), 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 63, 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 Code in case of my death.

Signature of an Attester in case Signature or

impression of woman the woman is not able to

sign and affix thumb impression.

Date…………

PART II

FORM OF RECEIPT OF MATERNITY BENEFIT

[See Rule 22 (2) (c)]

I………………………………, the undersigned, a woman employee/ the nominee

of…… woman employee/ 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 from the

employer of the establishment referred to above, as detailed below: -

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

Rs…… being the second instalment 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 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 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.

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

Date………

(*Strike out unnecessary portion)