Form XIV

[See Rule 11(1)(a)]

Complaint to the Inspector-cum-Facilitator

To,

The Inspector-cum-Facilitator

(Under The Code on Social Security, 2020)

Sir,

I………………… (Name of woman employee) employed in…… (name and full

address of the establishment) or I…….............., (name), a person nominated under section 62

by or a legal representative of…..........................…(name of woman employee) employed

in…….(name and full address of the establishment) having fulfilled the conditions laid down

in the Code on Social Security , 2020 and the Rules framed thereunder, am entitled to

Rs…….......................... being maternity benefit and/ or Rs….......................… being the

medical bonus and/ or Rs…...........……. being wages for leave due under section 65 but the

same has been improperly withheld by the employer/discharged or dismissed during or on

account of her/my absence from work in accordance with the provisions of this Chapter VI

of Code on Social Security, 2020.

You are therefore requested, to direct the employer to pay the amount to me/ to set

aside the discharge or dismissal done by the employer.

Signature or thumb impression of the Woman/

nominee/ legal representative

Place ……………

Date…………….

Signature of an Attester in case the woman/

nominee/ legal representative is

unable to sign and affixes thumb impression.

Full address of the women/nominee/legal representative.