Maternity Benefit Statement Of Earnings
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1
2NATIONAL INSURANCE AND SOCIAL SECURITY ACT, 1969
MATERNITY BENEFIT - STATEMENT OF EARNINGS
(This form is to be completed by the Employer
and given to the Employee to take or send to
the nearest National Insurance Office)
WARNING:
Any person who knowingly makes a false statement or false representation for the purpose of obtaining
any payment for himself or for some other person under the National Insurance and Social Security Act,
1969 or produces or furnishes any document or information which he knows to be false in a material
particular, renders himself liable to prosecution.
1.
PARTICULAR OF EMPLOYER:
(a)
NAME OF EMPLOYER/BUSINESS:
(b)
NATURE OF BUSINESS:
(c)
ADDRESS OF BUSINESS:
(d)
EMPLOYER’S REGISTRATION
NUMBER:
2.
PARTICULARS OF EMPLOYEE:
(a)
NAME OF EMPLOYEE:
(b)
ADDRESS OF EMPLOYEE:
(c)
NATIONAL INSURANCE NO:
(d)
NATIONAL REGISTRATION NO:
3.
PARTICULARS OF EMPLOYMENT:
(a)
Has Employee been in your employment over the last 15 weeks?
Yes
No
If the answer to (a) above is No,
(b)
How long has employee been in your employment?...............................................................................................
(c)
How many contributions have you paid for employee during period referred to at (a) or (b) above?
(d)
Salary/wage paid to employee for last 6 months/26 weeks worked
MONTH
SALARY
WEEK ENDING
WAGE
WEEK ENDING
WAGE
1.
$
1.
$
14.
$
2.
$
2.
$
15.
$
3.
$
3.
$
16.
$
4.
$
4.
$
17.
$
5.
$
5.
$
18.
$
6.
$
6.
$
19.
$
7.
$
20.
$
8.
$
21.
$
9.
$
22.
$
10.
$
23.
$
11.
$
24.
$
12.
$
25.
$
13.
$
26.
$
(e)
Last date employee worked:
(f)
Rate of salary/wage to be paid to employee when absent from work:
$............................................................ per month/week. From ....................................... to ................................
((f) above to be completed only when employee will be paid during period of maternity benefit)
I certify that the above statements are true to the best of my belief and knowledge and I assume full responsibility
as to their correctness.
Signature of Employer (or Rep): ...................................................................
Date: ....................................................................
FORM MB1 (REVISED 95)
Employer Stamp:
(R & P Dept. May 1999)
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