Form XXVIII (A)

[See Rule 69(1)]

MEMORANDUM OF AGREEMENT

It is hereby submitted that on the _________day of 20 _______ the said employee has been in receipt

of half-monthly payments which have continued from the ______day of 20____ until the day _____ of 20____

amounting to `_________ in all. The said employee’s monthly wages are estimated at ` _____. The employee

is over the age of 15 years/will reach the age of 15 years on ________

It is further submitted that _________the employer of the said employee, has agreed to pay and the said

employee has agreed to accept, the sum of `_______ in full settlement of all and every claim under the Chapter

VII of the Code on Social Security, 2020 in respect of all disablement of temporary nature arising out of the said

accident, whether now or hereafter to become manifest, it is, therefore requested that this memorandum be

duly recorded.

Dated _____________ 20___ Signature of the employee_______________

Witness_____________________________

Signature of the employer_____________

Witness____________________________

Note: — An application to register an agreement can be presented under the signature of the one party, provided

that the other party has agreed to the terms. But both signatures should be appended whenever

possible.

Receipt (To be filled in when the money has been actually paid).

In accordance with the above agreement, I have this day received the sum

of `__________

Signature of the employee

Dated ____________ 20__________

The money has been paid and this receipt signed in my presence.

Signature of Witness

(Note: — This form may be varied to suit special cases, e.g. injury by occupational diseases, agreement when

employee is under legal disability, etc.)