Form XIII B

[See rule 39 (2) (b)]

Appeal

To,

The Appellate Authority,

(Appointed under the Code on Social Security, 2020)

……………………………………………(Address)

Sir,

I………, the undersigned, woman employee/her legal heir/her representative or employer/his

representative of……… (name and full address of the establishment) aggrieved by the order of

Inspector-cum-Facilitator Shri…….. hereby prefer this Appeal under sub-section (3) of section 72 in

view of the facts mentioned in the memorandum and other documents filed herewith.

*Denial by his order under sub-section (2) of section 72, the maternity benefit or other amount

……… (Nature of amount) to which……… (Name of woman employee) is entitled and/or refused to

set aside discharge or dismissal of …….. (Name of woman employee) 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)(Strike out unnecessary portion).

*It is submitted that the ……….. (Name of woman employee) is not entitled to the maternity benefit

or the said amount and/or rightly discharged or dismissed hence the order of the Inspector-cum-

Facilitator may be set aside.

*Strike out unnecessary portion.

Signature or thumb impression of the Woman employee/Aggrieved person/Employer

Place.............

Date………

…………………………………………………………………..

Signature of an Attester in case the woman employee is

not able to sign and affixes thumb impression.

Full address of the nominee/legal representative