Form XXV

[See Rule 63(2)]

APPEAL

To,

The Authority,

(Appointed under the Code on Social Security, 2020)

…………………………………………… (Address)

Sir,

I……………………………………......................................., the undersigned, woman employee

of……………………………...................... (name and full address of the establishment)

*Feeling aggrieved by the order of Inspector-cum-Facilitator under sub section (2) of Section

72 for the reasons attached hereto, prefer this appeal under sub-section (2) of section 68 and request

that the said employer be ordered to pay the above mentioned amount to me. A copy of the order of

Inspector-cum-Facilitator cum Facilitator in this behalf is enclosed ; or

*Shri………………………, Inspector-cum-Facilitator, having directed under sub-section (2) of

Section 72 to pay the maternity benefit or other amount being……………… (Nature of amount) to

which………..…… (Name of woman) is said to be entitled/to set aside my discharge or dismissal

during or on account of absence from work in accordance with the provisions of this Chapter VI of the

Code on Social Security, 2020(Strike out unnecessary portion).

I prefer this appeal under sub-section (3) of Section 72. In view of the facts mentioned in the

memorandum attached hereto and other documents filed herewith it is submitted that the woman is

not entitled to the maternity benefit or the said amount and hence the order of the Inspector-cum-

Facilitator a copy of which is enclosed, may be set aside.

*Strike out unnecessary portion.

Signature or thumb impression of the Women/Aggrieved person

Date………

Signature of an Attester in case the woman is

not able to sign and affixes thumb impression.

Full address of the nominee/legal representative