Forms Required to be Maintained Under Maternity Benefit Act 1961

Please find attached the Form A & annual return Form KLMN as per Haryana government rules.


FORM “A”

(See rule 3)

Muster Roll

 

             Name of the Establishment                                       M/S  

 

  1. Serial Number

 

  1. Name of the women and her father’s                      Mrs.         W/o Mr. Arun Bajaj

(or if married husband’s name)

 

  1. Date of appointment                                               03/04/20

 

  1. Nature of work                                                        ??/

 

  1. Date with month and year in which

 

 

Month No. of days employed No. of days laid off No. of days not employed remarks
JAN 31
FEB 28
MAR 31
APR 30
MAY 31
JUN 30
JUL 31 20   (on MaternityLeave w.e.f31     12nd July 07

30      to 9th Oct07)

09

AUG 31
SEP 30
OCT 31
NOV 30
DEC 31

 

 

 

6.         Date on which women gives notice under section 6

 

7.         Date of discharge or dismissal, if any

 

8.         Date of production of proof of pregnancy under section 6

 

9.         Date of Birth of child :                                                   18/07/2007

 

10.       Date of production of proof of delivery of miscarriage

of death

 

11.       Date of production of proof of illness referred to in

section 10

 

12.       Date with the amount of maternity benefit paid in

advance of expected delivery

 

13.       Date with the amount of subsequent payment of

maternity benefit .

 

14.       Date with the amount of medical bonus, if paid under

section 8.

 

15.       Date with the amount of wages paid on account of

leave under section 9.

 

16.       Date with the amount of wages paid on account of

leave under section 10 and period of leave granted.

 

17.       Name of the person nominated  by the women under

section 6.

 

18.       If the women dies, the date of her death, the name of the

person to whom maternity benefit and or other  amount

was paid , the amount thereof and the date of payment.

 

19.       If the women dies and the child survive the name of the

person to whom the amount of maternity benefit was

paid on behalf of the child and the period for which

if was paid

 

20.       Signature of the employer of the establishment

authenticating the entries in the must Roll.

 

21.       Remarks Column for the use of inspector;

 

 Click Here To download annual return form KLMN

Click Here To download Form for maternity benefit act 1961