The Code on Social Security (Mizoram) Rules, 2026
Form XII
Official text
Open in the official PDF (p. 45)
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[(SEE RULE 8(13)]
APPLICATION FOR RECOVERY OF GRATUITY
Before the Competent Authority for Chapter V under the Social Security Code, 2020
Application No.... Date........
BETWEEN
(Name in full of the applicant with full address)
AND
(Name in full of the employer/Trust/Insurer concerned with full address)
1. 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
………………an employee of the above-mentioned employer, and you were pleased to direct
the said employer in your notice dated the ……………………….of Code on Social Security
(Mizoram) Rules, 2021 for payment of a sum of Rs…………………. as gratuity payable under
the Code on Social Security, 2021.
2. The applicant submits that the said employer failed to pay the said amount of gratuity to me as
directed by you although I approached him for payment.
3. The applicant, therefore, prays that a certificate may be issued under section 129 of the Code for
recovery of the said sum of Rs. …………… due to me as gratuity in terms of your direction.
Signature/Thumb-impression of applicant.
Place:
Date:
Note. — Strike out the words not applicable.