Form XV

[See Rule 23 (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.

Date………

Signature or thumb impression of the

Women/Aggrieved person…………………….

Signature of an Attester in case the woman is

not able to sign and affixes thumb impression.

Full address of the nominee/legal representative