Form VI

[(See rule 33(4)]

Application for Direction

Before the Competent Authority for Chapter V under the Code on Social Security, 2020

Application No. Date

BETWEEN

(Name in full of the applicant with full address)

AND

(Name in full of the employer concerned with full address)

The applicant is an employee of the above-mentioned employer/a nominee of

late………………………… an employee of the above-mentioned employer/a legal heir of

late………………………… and employee of the above-mentioned employer, and is entitled to

payment of gratuity under section 53 of the Code on Social Security, 2020 (36 of 2020) on account of

his own/aforesaid employee's superannuation on……………………………(date)/his own

retirement/aforesaid employees' resignation on…………………..(date) completion

of…………………years of continuous service/his own/aforesaid employees' total disablement with

effect from ………………….(date)due to accident/disease death of aforesaid employee

on……………….

2. The applicant submitted an application under rule…………………… of the Social Security

(Central) Rules, 2026 on the ……………….but the above-mentioned employer refused to entertain

it/issued a notice dated the……………. under clause ………….of sub-rule of rule

……………….offering an amount of gratuity which is less than my due/issued a notice dated the

……………….. under clause…………. of sub-rule…………of rule………………. rejecting my

eligibility to payment of gratuity. The duplicate copy of the said notice is enclosed.

3. The applicant submits that there is a dispute on the matter (specify the dispute).

4. The applicant furnishes the necessary particulars in the annexure hereto and prays that the

Competent Authority may be pleased to determine the amount of gratuity payable to the applicant and

direct the above-mentioned employer to pay the same to the applicant.

5. The applicant declares that the particulars furnished in the annexure hereto are true and correct to

the best of his knowledge and belief.

Place:

Date:

Signature/Thumb impression of the applicant.