Form XXVIII (C)

[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 temporary disablement to the said employee who is at present in receipt of wages amounting to

`___________ as wages per month.

The said employee monthly wages prior to the accident are estimated at Rs. __________. The

employee is subject to a legal disability by reason of____________________.

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

________________on the behalf of the said employee, has agreed to accept half monthly payments @ of `

_______________ for the period of the said temporary disablement. This agreement is subject to the condition

that the amount of the half monthly payments may be varied in accordance with the provision of the Chapter VII

of the Code on Social Security, 2020, on account of an alternation in the earning of the said employee during

disablement .It is further, stipulated that all rights of communication under section 80 of the Code are unaffected

by this agreement. It is, therefore, requested that this memorandum be duly recorded.

Dated ___________ 20____

Signature of the employer

Witnesses_______________

Signature of the employee

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, etc.)