Form XI

[(See Rule 8(11) and (12)]

Notice for Payment of Gratuity as Determined by Competent/Appellate Authority

(Strike out the words not applicable)

To,

(Name and address of employer)

1. Whereas Shri/Smt …………………………………… of an employee

…………………………………………………… (address) under you/ a nominee(s)/legal heir(s) of late

………………………………………………an employee under you, filed an application under section 56

of the Code on Social Security, 2020, before me; or

Whereas a notice was given to you on ……………………. requiring you to make payment of

Rs……………………to Shri/Smt ………………………………as gratuity under the Code on Social

Security, 2020.

2. And whereas the application was heard in your presence on………...and after the hearing

has come to the finding that the said Shri/Smt ………………is entitled to a payment of Rs……………

as gratuity under the Code on Social Security, 2020; or

Whereas you/the applicant went in appeal before the appellate authority, who has decided that

an amount of Rs…………………. is due to be paid to Shri/Smt as gratuity due and the amount as interest

due under The Code on Social Security, 2021.

Now, therefore, I hereby direct you to pay the said sum of Rs. ………………….to Shri/Smt

………………………………. within thirty days of the receipt of this notice with an intimation thereof

to me.

Given under my hand and seal, this ……….day of……………….20………...

Competent Authority

under the Code on Social Security Code, 2020

Copy to:

1. The Applicant- He is advised to contact the employer for collecting payment.

2. The Appellate Authority if applicable.

Note. --- (Strike out paragraphs if not applicable).