FORM 'I' (See Rule 10) To The Inspector, (Under the Maternity Benefit Act, 1961) I, (name), a person nominated under Sec. 6 by or a legal representative of .... ......(name of woman) employed in .....(name and full address of establishment) have to complain that the said woman having fulfilled the conditions laid down in the Maternity Benefit Act, 1961 and the rules there under is entitled to Rs. being maternity benefit and/ or Rs. being the medical bonus and/or Rs. being wages for leave due under Sec. 9 or 10 but the same has been improperly with-held by the employer. He may, therefore, be directed to pay the amount to me. Signature or thumb impression of the nominee/legal representative. 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.
