Form VII

[(See Sub-Rule (13) of Rule-19]

Application for Recovery of Gratuity

Before the Competent Authority for Chapter-IV under the Social Security

Code, 2020

Application No.

BETWEEN

(Name in full of the applicant with full address)

AND

(Name in full of the employer/Trust/Insurer concerned with full address)

1. 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 ………………an employee of the above-mentioned employer, and you were

pleased to direct the said employer in your notice dated the

………………………..under sub-rule (11) or sub-rule (12) of rule 19 of Code on

Social Security (Andhra Pradesh State) Rules, 2026for payment of a sum of

Rs………………….. as gratuity payable under the Code on Social Security, 2020.

2. The applicant submits that the said employer failed to pay the said amount of

gratuity to me as directed by you although I approached him for payment.

3. The applicant therefore prays that a certificate may be issued under section

129 of the Code for recovery of the said sum of Rs. ………………………. due to me

as gratuity in terms of your direction.

Signature/Thumb-impression of applicant.

Place:

Date:

Note.—Strike out the words not applicable.