Home / Code on Social Security / Central Rules 2026
Form guide · Source checked 21 October 2026
Social Security Form XI: maternity notice and payment receipt
Woman employee’s maternity notice and separate receipt of amounts paid under sections 62 and 63.
See rule 35 (2)(a) and (c) · Social Security (Central) Rules, 2026 · Central-sphere scope
Download and read the completed example
Completed fictional maternity notice and payment receipt for Sahyadri Illustration Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001. It illustrates the prescribed fields without executing a signature or official act.
Fictional, unsigned completed illustration. It demonstrates this form’s fields; it is not a filed return, medical opinion, official order or proof of an actual transaction.
When and how this form is used
The notice and receipt are separate parts. A notice of expected absence is not proof that benefit has been paid; complete Part II only for actual amounts received.
The sample assumes the eligibility/service and fewer-than-two-surviving-children conditions for 26 weeks. The daily rate must be the legally applicable highest rate; the ₹1,000 figure is a scenario assumption, not a national minimum wage.
The completed fields
Part I — notice
| Prescribed field / section | Completed fictional entry |
|---|---|
| Woman / parent / establishment | Priya Rao, daughter of Meera Rao (fictional), Sahyadri Illustration Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001 |
| Employment / contact | Accounts assistant; employee DEMO-MAT-01; priya@example.invalid; 6 Example Road, New Delhi 110001 |
| Delivery / leave scenario | Expected and actual illustrative delivery 20 September 2026; maternity absence from 9 August 2026; fewer than two surviving children assumed |
| Daily benefit assumption | ₹1,000 average daily wage is assumed higher than the applicable minimum and statutory floor; 26 weeks = 182 days |
| Notice / absence / undertaking | Notice 9 August 2026; absent from 9 August 2026; employee undertakes not to work during benefit period |
| Nominee for amounts on death | Rohan Rao (fictional), 6 Example Road, New Delhi 110001 |
| Woman / attester / date | Priya Rao; attester N/A because woman can sign; 9 August 2026; Signature / seal / certification not executed; typed name is an illustration only |
Part II — receipt
| Prescribed field / section | Completed fictional entry |
|---|---|
| Recipient / employer / district | Priya Rao personally; Sahyadri Illustration Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001; New Delhi |
| First instalment | ₹42,000 on 9 August 2026 for 42 pre-delivery days |
| Second instalment | ₹1,40,000 on 22 September 2026 for 140 remaining days |
| Medical bonus | ₹3,500 on 22 September 2026; assumes employer provides no free qualifying pre-/post-natal care |
| Section 65 additional leave wages | Nil; no miscarriage, tubectomy or additional illness leave in this scenario |
| Delivery / amount / place / date | 20 September 2026; total receipt ₹1,85,500; New Delhi, 22 September 2026; Signature / seal / certification not executed; typed name is an illustration only |
Supporting records and reconciliation
Employment/attendance and wage records, genuine Form X or permitted proof, notice, nominee details and actual instalment/bonus payment records.
Worked calculation: 42 × ₹1,000 = ₹42,000; 140 × ₹1,000 = ₹1,40,000; benefit ₹1,82,000 + ₹3,500 medical bonus = ₹1,85,500.
Official source and version
Official Gazette, Social Security (Central) Rules, 2026; Form XI; PDF pages 217–218
Download the official source pages containing this form. Adjacent prescribed forms can share a source page; use the heading and rule identified above.
The Central Rules have their stated jurisdiction. The corresponding appropriate-government rules and any later amendment must match the real establishment and event.
Practical questions
Can I submit the sample as my own completed form?
No. Replace the fictional facts with accurate records, use the competent filing or record-keeping route described above and complete genuine signatures or certifications where required.
What makes the example specific to this form?
This is the prescribed maternity notice and payment receipt under See rule 35 (2)(a) and (c), with its own parties, event, required entries and legal function.