Form V

[(See Sub-Rule (5), (8) of Rule-19]

Notice for Appearance before the Competent Authority/Summon

To:

(Name and address of the employer/applicant)

Whereas Shri …………………………….………………….an employee under you/a

nominee(s)/legal heir(s) of Shri………………………………….an employee under the

above-mentioned employer, has/have filed an application under sub-rule (4) of

rule 19of the Code on Social Security (Andhra Pradesh State) Rules, 2026 alleging

that----

(A copy of the said application is enclosed, if, summon is issued then copy of

application is not required)

2. Now, therefore, you are hereby called upon/summoned to appear before the

Competent Authority at…………………. (place) either personally or through a

person duly authorized in this behalf for the purpose of answering all material

questions relating to the application on the …. day of …………20…. at

…………….'O' clock in the forenoon/afternoon in support of/to answer the

allegation; and as the day fixed for your appearance is appointed for final disposal

of the application, you must be prepared to produce on that day all the witnesses

upon whose evidence, and the documents upon which you intend to rely in

support of your allegation/defence.

3. Take notice that in default of your appearance on the day before-mentioned,

the application will be dismissed/heard and determined in your absence.

4. Whereas your attendance is required to give evidence/you are required to

produce the documents mentioned in this list below, on behalf of ………. in the

case arising out of the claim for gratuity by………. Form…………. and referred to

this Authority by an application under section 56 of the Code on Social Security,

2020, you are hereby summoned to appear personally before this Authority on

the ……. day of …….20……………. at ………… ‘O’clock in the forenoon/afternoon

and to bring with you for to send to this Authority) the said documents.

List of documents-

1.

2.

3. so on

Given under my hand and seal, this …………. day of ………….20….

Competent Authority under the Code on

Social Security Code, 2020

Note:

1. Strike out the words and paragraphs not applicable.

2. The portion not applicable to be deleted.

3. The summons shall be issued in duplicate. The duplicate is to be signed and

returned by the persons served before the date fixed.

4. In case the summons is issued only for producing a document and not to given

evidence it will be sufficient compliance to the summons if the documents are

caused to be produced before the Competent authority on the day and hour fixed

for the purpose.