Form I

[See rule 13 (2)(a)]

APPEAL UNDER SECTION 23 OF THE CODE ON SOCIAL SECURITY, 2020

Title of the case:

APPEAL

INDEX

Serial No. Description of documents relied Page No.

1.

2.

3.

4.

Signature of the Applicant

For use in Tribunal’s office

Date of filing (or) Date of receipt by post Registration

No.

Signature of Registrar

IN THE CENTRAL GOVERNMENT INDUSTRIALTRIBUNAL

BETWEEN

A.B. APPELLANT

Vs.

C.D. RESPONDENT

DETAILS OF APPEAL

1. Particulars of the Appellant:

i. Name of the appellant

ii. Office address

iii. Address for service ofnotices

2. Particulars of the Respondent:

i. Name of therespondent

ii. Office address

iii. Address for service ofnotices

3. Particulars of the order/notification against which appeal is made.- The appeal is against

the followingorder/notification

i. Order/notification No. with reference to Annexure

ii. Date

iii. Passed by

iv. Subject inbrief

4. Jurisdiction of the Tribunal.- The appellant declares that the subject of the matter against

which he wants redressal is within the jurisdiction of theTribunal.

5. Limitation. —The appellant further declares that the appeal is within the limitation specified

in section 126 of the Code on Social Security, 2020 (36 of 2020).

6. Facts of the case.- The facts of the case are given below:

(Give here a concise statement of facts in a chronological order, each paragraph

containing as nearly as possible a separate issue, fact or otherwise)

7. Details of remedies exhausted. —The appellant declares that he has availed of all the

remedies available to him under the Code.

(Give here chronologically the details of representations made and the outcome of

such representation with reference to the Annexure numbers).

8. Matters not previously filed or pending with any other Court. —The appellant further

declares that he had not previously filed any appeal, writ petition or suit regarding the matters

in respects of which this appeal has been made, before any court of law or any other authority

or any other bench of the Tribunal nor any such appeal, writ petition or suit is pending before

any ofthem.

In case the appellant has previously filed any appeal, writ petition or suit, the

stage at which it is pending and if decided, the gist of the decision should be given

with reference to the Annexure.

9. Relief(s) sought. —In view of the facts mentioned in para 6 above, the appellant prays for the

following relief(s):--

[Specify below the relief(s) sought explaining the ground for relief(s) and the legal

provisions (if any) relied upon].

10. Interim order, if any, prayed for. —Pending final decision on the appeal the applicant seeks

issue of the following interim order—

(Give here the nature of the interim order prayed for with reasons)

11. In the event of appeal being sent by speed post (with registration), it may be stated whether

the appellant desires to have oral hearing at the admission stage and if so, he shall attach a

self-addressed Post Card, Inland Letter, at which intimation regarding the date of hearing

could be sent tohim.

12. Particulars of Bank Draft or Postal order in respect of the Appeal Fee:

13. Name of the Bank on which drawn

14. Demand Draft No. (OR)

15. Details of online fund transfer

16. List ofenclosures

1.

2.

3.

4.

5.

6.

VERIFICATION

I, ………………………… (Name of the Appellant) S/O, D/O, W/O …………………..

Age…………. working as ………..in the office of …………………. resident of …………. do

hereby verify that the contents of paras ………. to……………. are true to my personal knowledge

and paras …….. to………. believed to be true on legal advice and that I have not suppressed any

material fact.

Signature of the Appellant

Date:

Place:

To

The Registrar