Form XVII

[See Rule 60(4)]

APPLICATION FOR DIRECTION

Before the Competent Authority for Ch

apter V under the Code on Social Security, 2020

Application No. Date :

BETWEEN

(Name in full of the applicant with full address)

AND

(Name in full of the employer 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………………………… and employee of the above mentioned 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 (State) Rules, 2021 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.

ANNEXURES:

1. Name in full of applicant with full address

2. Basis of claim (Death/Superannuation/Retirement/Resignation/Disablement of Employee /

Completio of contract period under Fixed Term Employment)

3. Name and address in full of the employee

4. Marital status of the employee (unmarried/married/widow/widower/divorced)

5. Name and address in full of the employer

6. Department/Branch/Section where the employee was last employed (if known)

7. Post held by the employee with Ticket or Sl. No., if any (if known)

8. Date of appointment of the employee (if known)

9. Date and cause of termination of service of the employee (Superannuation / retirement /

resignation /disablement / death/Completion of contract period under Fixed Term Employment)

10. Total period of service by the employee

11. Wages last drawn by the employee

12. If the employee is dead, date and cause thereof

13. Evidence/witness in support of death of the employee

14. If a nominee, No. and date of recording of nomination with the employer

15. Evidence/witness in support of being a legal heir, if a legal heir

16. Total gratuity payable to the employee (if known)

17. Percentage of gratuity payable to the applicant as nominee/legal heir

18. Amount of gratuity claimed by the applicant

Place :

Date: Signature/Thumb-impression of the applicant