Form XII

Made under The Code on Social Security, 2020F. No. 08/03/2024-LE&T/72, 25 Mar 2026

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[(See Rule 20(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 under sub-rule (11) or sub-rule (12) of rule 35 of Code on

Social Security (Central) Rules, 2020 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.

Source: The Code on Social Security (Lakshadweep) Rules, 2025, F. No. 08/03/2024-LE&T/72 — Lakshadweep Gazette Extraordinary Vol. LXI, No. 61, p. 45 of the PDF. Open our copy at p. 45 · official download · all sources