The Social Security (Central) Rules, 2026
Form XII
Official text
Open in the official PDF (pp. 218–219)
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[seerule 38 (2)]
Appeal under Section 68
To
The Competent Authority
(Appointed under Chapter VI of Code on Social Security, 2020)
……..(Address)
Sir,
I, ..…. The undersigned, woman employee of ….(name and full address of the establishment)
have been wrongly deprived by the employer of maternity benefit or medical bonus or both or
wrongly discharged or dismissed during or on account of absence from work in accordance with the
provisions of Chapter VI of the Code on Social Security, 2020(36 of 2020) for the reasons attached
hereto, prefer this appeal under sub-section (2) of section 68 and request that the said employer be
ordered to pay the above mentioned amount to me and/or set aside the order of discharge/dismissal. A
copy of the order of the employer in this behalf is enclosed.
Signature or thumb impression of the Woman employee/
nominee/ legal representative
Place...........
Date…………
Signature of an Attester in case the woman employee/
nominee/ legal representative is
unable to sign and affixes thumb impression.
Full address of the woman employee /nominee/legal representative.