Form XI

Appeal

[See Rule (2) (b) of Rule-26]

To,

The Authority,

(Appointed under the Code on Social Security, 2020)

……………………………………………(Address)

Sir,

I………………………………………………………………………………,the undersigned,

woman employee of…………………….…………………………………………………………

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

Inspector-cum-Facilitator under sub section (2) of section 72 for the reasons

attached hereto, prefer this appeal under sub-section (2) of section 68 and

request that the said employer be ordered to pay the above-mentioned amount to

me. A copy of the order of Inspector-cum-Facilitator cum Facilitator in this behalf

is enclosed; or

Shri……………………………………………………………………………..., Inspector-cum-

Facilitator, having directed under sub-section (2) of section 72 to pay the

maternity benefit or other amount being……… (Nature of amount) to which………

(Name of woman) is said to be entitled/to set aside my discharge or dismissal

during or on account of absence from work in accordance with the provisions of

this Chapter VI of the Code on Social Security , 2020 (Strike out unnecessary

portion).

I prefer this appeal under sub-section (3) of section 72. In view of the facts

mentioned in the memorandum attached hereto and other documents filed

herewith it is submitted that the woman is not entitled to the maternity benefit or

the said amount and hence the order of the Inspector-cum-Facilitator in the copy

of which is enclosed, may be set aside.

Date: ……….. Signature or thumb impression

of the Women/Aggrieved person

Signature of an Attester in case the woman is

not able to sign and affixes thumb impression.

Full address of the nominee/legal representative