Form IV

[(See Rule (4) of Rule 19]

Application for Direction Before the Competent Authority for Chapter V

under the Code on Social Security, 2020

Application No.

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 abovementioned employer,

and is entitled to payment of gratuity under section 53 of the Code on Social

Security, 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 Code

on Social Security (Andhra Pradesh) 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 petitioner and direct the above-mentioned employer to pay

the same to the petitioner.

5. The applicant declares that the particulars furnished in the annexure hereto

are true and correct to the best of his knowledge and belief.

Date:

Signature/Thumb impression of the applicant.