Form XII

[(See Rule 8(13)]

Application for Recovery of Gratuity

Before the Competent Authority for Chapter V under the Social Security Code, 2020

Application No. Date

BETWEEN

(Name in full of the applicant with full address)

AND

(Name in full of the employer/Trust/Insurer concerned with full address)

1. The applicant is an employee of the above-mentioned employer/a nominee of

late…………………… an employee of the above mentioned employer/a legal heir of late

………………an employee of the above-mentioned employer, and you were pleased to

direct the said employer in your notice dated the ……………………….. for payment of a

sum of Rs………………….. as gratuity payable under the Code on Social Security, 2020.

2. The applicant submits that the said employer failed to pay the said amount of gratuity

to me as directed by you although I approached him for payment.

3. The applicant therefore prays that a certificate may be issued under section 129 of the

Code for recovery of the said sum of Rs. …………… due to me as gratuity in terms of your

direction.

Signature/Thumb-impression of applicant.

Place:

Date:

Note.—Strike out the words not applicable.