Form X

[See Sub-Rule (2)(a) of Rule-25]

Complaint to the Inspector-cum-Facilitator

To,

The Inspector-cum-Facilitator

(Under The Code on Social Security, 2020)

Sir,

I……………………………………………………………….. (Name of woman) 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) employed in…….(name

and full address of the establishment) having fulfilled the conditions laid down in

the Code on Social Security , 2020 and the Rules there under, 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 her absence from work in accordance with the

provisions of this Chapter V of Code on Social Security, 2020.

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

set aside the discharge or dismissal done by the employer.

Signature or thumb impression of the Woman/

nominee/ legal representative

Date…………

Signature of an Attester in case the woman/

nominee/ legal representative is

unable to sign and affixes thumb impression.

Full address of the women/nominee/legal representative.