[Regulations 88 and 89]
I,__________ wife/daughter of ______________________, Insurance No ___________, hereby claim maternity benefit w.e.f_________________ day of ___________________ 19___
I hereby declare that I have ceased/shall cease to work for remuneration with effect from that date.
Present/ last employer (if changed)_________________________
Present address (if changed)_______________________________
Signature or thumb impression _______
Local office ______________________
Notes : 1. Any person who makes a false statement or representation for the purpose of obtaining benefit whether for oneself or for some other person renders oneself liable to prosecution.
2. No work for remuneration should be taken up during the period for which maternity benefit is being or is to be claimed. Notice of resumption of work in Form No. 24 must be sent before any work is taken up.