The Code on Social Security (Arunachal Pradesh) Rules, 2021
Form XXVIII (B)
Official text
Open in the official PDF (pp. 62–63)
Tables and forms lose their layout when extracted; the PDF is the authoritative version.
[See Rule 69(1)]
MEMORANDUM OF AGREEMENT
It is hereby submitted that on the __________ day of 20_____ ,personal injury was caused to ____
residing at ______ by accident arising out of and in the course of his employment in ________. The said injury
has resulted in permanent disablement to the said employee of the following nature, namely:—
The said employee monthly wages are estimated at ` ________. The employee is over the age of 15
years/will reach the age of 15 years on __________. The said employee has prior to the date of this agreement,
received the following payment, namely:—
`___________ on ____________ `__________ on __________
`___________on____________ `__________on ___________
`___________on____________ `__________on ___________
It is further submitted that __________ the employer of the said employee, has agreed to pay the said
employee who 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 the disablement started above and all
disablement now 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 the agreement can be presented under the signature of the one party,
provided that the other party has agreed to the terms. But both signature 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.).