Form XV

[See Rule 11 (2) (b)]

Appeal

To,

The Authority,

(Appointed under the Code on Social Security, 2020)

…………………………………………… (Address)

Sir,

I………, the undersigned, woman employee of……… (name and full address of the

establishment)

*Feel aggrieved by the order of Inspector-cum-Facilitator under sub section (2) of

section 72 for the reasons attached hereto, prefer this appeal under sub-section (2) of section

68 and request that the said employer be ordered to pay the above mentioned amount to me.

A copy of the order of Inspector-cum-Facilitator cum Facilitator in this behalf is enclosed; or

*Shri…................................…, Inspector-cum-Facilitator, having directed under sub-

section (2) of section 72 to pay the maternity benefit or other amount being…................……

(Nature of amount) to which…...............................…… (Name of woman) is said to be

entitled/to set aside my discharge or dismissal during or on account of absence from work in

accordance with the provisions of this Chapter V of the Code on Social Security, 2020(Strike

out unnecessary portion).

I prefer this appeal under sub-section (3) of section 72. In view of the facts

mentioned in the memorandum attached hereto and other documents filed herewith it is

submitted that the woman is not entitled to the maternity benefit or the said amount and

hence the order of the Inspector-cum-Facilitator in the copy of which is enclosed, may be set

aside.

*Strike out unnecessary portion.

Signature or thumb impression of the Women

/Aggrieved person

Place ………….

Date…………..

Signature of an Attester in case the woman is

not able to sign and affixes thumb impression.

Full address of the nominee/legal representative