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
- Serial Number
- Name of the women and her father’s Mrs. W/o Mr. Arun Bajaj
(or if married husband’s name)
- Date of appointment 03/04/20
- Nature of work ??/
- 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