Form XVIII B

[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 and

in the course of his employment in…………………. The said injury has resulted in

death to the said workman. The said employee's monthly wages are estimated at Rs...........The

employee is over the age of 15 years will reach the age of 15 years on ..........................

The said employee has, prior to the date of the agreement, received the following payments,

namely: --

Rs. ..................... on ................ Rs. on

Rs.................... on .............................Rs. on

Rs.......................on .................. Rs on

It is further submitted that the employer of the said employee has agreed to pay, and dependent

(s) of the said employee has agreed to accept, the sum of Rs....... in full settlement of all and

every claim under the Code on Social Security, 2020 in receipt of death stated above. It is

therefore requested that this memorandum be duly recorded.

Dated ..........................20......... Signature of

Employer Witness

Witness Signature or dependent(s)

Note- Application to register an agreement can be presented under 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...................

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

Dependent(s) The money has been paid and this receipt signed in my presence.

Witness