Form XXIV

[See Rule 63(1)]

COMPLAINT TO THE INSPECTOR-CUM-FACILITATOR

To,

The Inspector-cum-Facilitator

(Under The Code on Social Security, 2020)

Sir,

I ………………………… (Name of woman) employed in ……………………………………..……

(name and full address of the establishment) or I …………………….……, (name), a person nominated

under Section 62 by or a legal representative of……(name of woman) employed in…….(name and full

address of the establishment) having fulfilled the conditions laid down in the Code on Social Security,

2020 and the Rules thereunder, am entitled to Rs…………… being maternity benefit and/ or

`……….… being the medical bonus and/ or `………….…. being wages for leave due under Section

65 but the same has been improperly withheld by the employer/discharged or dismissed during or on

account of my/ her absence from work in accordance with the provisions of this Chapter VI of the

Code on Social Security , 2020.

You are therefore requested, to direct the employer to pay the amount to me/ to set aside the

discharge or dismissal done by the employer.

Signature or thumb impression of the Woman/

Nominee/ legal representative

Date…………

Signature of an Attester in case the woman/

Nominee/ legal representative is unable to sign

and affixes thumb impression.

Full address of the women/ nominee/ legal representative.