Form XVIII A

[See Rule 29 (1)]

Memorandum of Agreement

It is hereby submitted that on the………. day of…………….20 ………….personal

injury was caused to .......................residing at by accident arising out of said in the course of

employment in……………... The said injury has resulted in temporary disablement to the said

employee, who is at present in receipt of wages amounting to Rs……….. per month/no

wages.

The said employee's monthly wages prior to the accident are estimated at Rs…...

The employee is subject to a legal disability by reason of.

It is further submitted that the employer of the employee has agreed to pay and on behalf of the

said employee has agreed to accept half-monthly payments at the rate of Rs......................for

the period of the said temporary disablement. This agreement is subject to the condition that

the amount of the half-monthly payments may be varied in accordance with provisions of the

said Act on account of an alteration in the earnings of the said employee during disablement.

It is further stipulated that all rights of commutation under Section 7 of the said Act are

unaffected by this agreement it is therefore requested that this memorandum be duly recorded.

Dated ................ 20.... .

Signature of employer Witness

Signature of employee Witness

Note- An application to register and agreement can be presented under the signature of one

party: provided that the other party has agreed to the terms. But both signatures should be

appended, whenever possible.

Receipt (to be filled in when the money has actually been paid).

In accordance with the above agreement, I have this day received the sum of Rs........ Employee

Dated………….20………

The money has been paid and this receipt signed in my presence.

Note- This form may be varied to suit special cases, e.g. injury by occupational disease etc.