Form XIV

[See Rule 23 (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) 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) 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

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

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.

Date…………

Signature or thumb impression of the Woman/

nominee/ legal representative

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.