The Social Security (Central) Rules, 2026
Form XIX
Official text
Open in the official PDF (pp. 228–229)
Tables and forms lose their layout when extracted; the PDF is the authoritative version.
[See rule 44(1)of the Social Security(Central) Rules, 2026 and section 105 of the Code on Social
Security, 2020)
Proforma for appeal before the Appellate Authority against Order of assessment or Order
imposing penalty
1 Name and address (permanent) of the establishment.
2 Name of the employer and address details
3 Name and address/ location of place where the building
or other construction is proposed to be carried on.
4 Name, designation and address of the authorised Person
along with contact details
5 Correspondence address for the proposed building or
other construction work
6 Nature of proposed construction work
7 Date of commencement of work(in case construction
has started)
8 Date of completion of work
9 Duration of work
10 Total completed area of construction work
11 Total estimated cost of the construction based on the
rates of (PWD or CPWD or RERA or some other rates,
as the case may be) along with documents (original) as
per Rule 41.
12 Total incurred cost of the construction work
13 Total amount of cess payable %age of total incurred cost of Total cess
the construction as notified by payable (in
the Central Government Rs.)
14 Advance cess paid, along with details (at the time of
approval of the Project or before the commencement of
the construction work) /deduction at source, if any
15 Details of cess paid (when duration of the proposed
construction work is more than one year)
Sl.No. Year Amount (in Rs.)
15.1 1st year
15.2 2nd Year
15.3 3rd Year
16 Total amount of the cess paid (Sl. No. 14 + Sl. No. 15)
17 Amount of outstanding cess (Sl. No. 13 – Sl. No.16)
18 Proof of payment of outstanding Cess, if any
19 Amount of overpaid cess, if applicable
20 Amount of cess assessed by the Assessing Officer
21 Amount of outstanding cess to be paid by the employer
22 Amount of penalty for non-payment of cess imposed /
outstanding cess claimed by the assessing officer.
23 Ground for appeal with supporting documents
24 Remarks, if any
Declaration
1. I/We hereby declare that the particulars given above are true to the best of my/our knowledge and
belief and I/We hereby declare that nothing has been concealed or any fact has been mis-represented
in the above calculation made by me/us.
2. I/We hereby declare that I/We am/are quite aware of the penal provisions of the Code on Social
Security, 2020 and if in future anything mentioned in the above self-assessment of cess amount, is
found to be incorrect or inappropriate or any incidence of hiding the facts or under calculation of cess
amount is found, punitive action may be taken against me/us.
Signature and seal of
employer
Name:
Date:
Place:
Mobile Number:
E-mail (if any):