Form IX

[(See Rule 20 (4)(i)(c)]

Application for Direction

Before the Competent Authority for Chapter V under the Code on Social Security, 2020

Application No. Date

BETWEEN

(Name in full of the applicant with full address)

AND

(Name in full of the employer concerned with full address)

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………..… and employee of

the above- mentioned employer, and is entitled to payment of gratuity under section 53 of the

Code on Social Security, 2020 on account of his own/aforesaid employee's superannuation

on……………………………(date)/his own retirement/aforesaid employees' resignation

on…………………..(date) completion of…………………years of continuous service/his

own/aforesaid employees' total disablement with effect from ………………….(date)due to

accident/disease death of aforesaid employee on……………….

2. The applicant submitted an application under Rule…………………… of the Code on

Social Security (Central) Rules, 2020 on the ……………….but the above-mentioned employer

refused to entertain it/issued a notice dated the……………. under clause ………….of sub-rule

of rule offering an amount of gratuity which is less than my due/issued a notice dated

………………..the under clause…………. of sub-rule… of rule… rejecting my

eligibility to payment of gratuity. The duplicate copy of the said notice is enclosed.

3. The applicant submits that there is a dispute on the matter (specify the dispute).

4. The applicant furnishes the necessary particulars in the annexure hereto and prays that

the Competent Authority may be pleased to determine the amount of gratuity payable to the

petitioner and direct the above-mentioned employer to pay the same to the petitioner.

5. The applicant declares that the particulars furnished in the annexure hereto are true and

correct to the best of his knowledge and belief.

Date:

Signature/Thumb impression of the applicant.