Form XIII A

[See rule 39(1)(a)]

Complaint to the Inspector-cum-Facilitator

To,

The Inspector-cum-Facilitator

(under the Code on Social Security, 2020)

Sir,

I…… (Name of woman employee) employed in…… (name and full address of the

establishment) or I……, (name), a person nominated under section 62 by or a legal representative

of……(name of woman employee) employed in…….(name and full address of the establishment)

having fulfilled the conditions laid down in the Code on Social Security, 2020(36 of 2020) and the

rules framed thereunder, am entitled to Rs…… being maternity benefit and/ or Rs…… being the

medical bonus and/ or Rs………. being wages for leave due under section 65 but the same has been

improperly withheld by the employer/discharged or dismissed during or on account of my/her absence

from work in accordance with the provisions of Chapter VI of Code on Social Security, 2020(36 of

2020).

You are, therefore, requested to direct the employer to pay the amount to me and/or to set

aside the discharge or dismissal done by the employer.

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.