Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694499902621.pdf (Antigua and Barbuda)
FOR OFFICAL USE ONLY Grant conditions satisfied 26wks in 52 prior to Yes No confinement Maternity Allowance condition satisfied 26 wks in 52 imm.

Yes No preceding 6wks before E.D.C.

Date of Monday 6 Wks prior to E.D.C.

D M Y PERIOD TO FROM NO.

OF WEEKS TOTAL EARNINGS A.I.W.E ANTIGUA & BARBUDA SOCIAL SECURITY BOARD APPLICATION FOR MATERNITY BENEFIT Section ‘A’ of this form must be completed and signed by a MEDICAL DOCTOR or a MIDWIFE registered in ANTIGUA-BARBUDA.
Section ‘B’ must be completed by the CLAIMANT.

Section ‘C’ must be completed by the EMPLOYER on or after the last day of work preceding the maternity leave.

NOTE TO CLAIMANT To avoid unnecessary delay in the processing of your benefit, please ensure that each section of this form is completed accurately as soon as possible after the commencement of your maternity leave.
After your confinement (birth), obtain a Certificate of Confinement Form from the Social Security Office, have it completed by your doctor or midwife who assisted at your confinement and return to the Social Security Office.

SECTION A TO BE COMPLETED BY A MEDICAL DOCTOR OR MIDWIFE REGISTERED IN ANTIGUA-BARBUDA To: Miss/Mrs.……………………………………………………………………I certify that I have examined you today and in my opinion you are pregnant.

It is expected that your Confinement will occur on…………………,,……………….

20…….
20…….

REMARKS (IF ANY)___________________________________________________ OR _____________________________________________________________________ ___________________________________________________________ To: Miss/Mrs …………………………………………………………………..I certify that I attended to you at your Confinement which took place on ……….

………………………………………………20…… Signature…………………..……..………………….. Date………………….………… NAME OF DOCTOR/MIDWIFE……………………………………………….. SIGNATURE…………………………………….

DATE……………………….
DATE……………………….

SECTION B TO BE COMPLETED BY CLAIMANT Name ………………………………………………Social Security No…….………….

Telephone No.

(H)……………………(C)……………………(W)………...………….. PAYMENT OPTION (Please choose one) Mailing Address………………………………………………………………………… Or Name: …………………………………….…….A/C Type……………A/C#......................................
PREVIOUS MONTH Weekly paid employee Monthly paid employee W/E 1…………………20….. $...................... 2…………………20….. $...................... 3…………………20….. $...................... ………………….20……… 4…………………20….

$...................... 5..……………….

20….

$...................... $............................................ for the month of Number of weeks worked……….

MONTH IN WHICH LEAVE STARTED Bank……………………………………………….
Address…………………………………... Weekly paid employee Monthly paid employee Employer Name……………………………………….. Address……………………………….

I claim Maternity Benefit from……………………20………… to ………………20………….

having last worked on…………………………….………………………..20………………….

During the past 14 months I was employed by:- Employer Address a) ………………………………………… ….…………………………… b) ………………………………………… ……………………………….

c) ………………………………………… ……………………………….


Signature…………………………………….…………… Date……………………………… W/E 1…………………20….. $...................... 2…………………20….. $...................... 3…………………20….. $...................... ………………….20…… 4…………………20….

$...................... 5…………………20….

$...................... $.................................... for the month of Number of weeks worked….

I certify that the above information given by me is correct to the best of my knowledge and belief.
I understand that I can be prosecuted if I knowingly give incorrect information.

SECTION C TO BE COMPLETED BY EMPLOYER NAME OF EMPLOYER ……………………………………………………………..

REGISTRATION NUMBER OF EMPLOYER This is to certify that Miss/Mrs ………………………………………….………………….

has been employed in this establishment from ……………………………20..………, her NAME OF PERSON GIVING INFORMATION ………………………………………… present weekly/monthly earnings being $.............................. She last worked on………….
20……… and should resume work on ……………...………………………20…………… SIGNATURE………………………………… DATE…………………………………….