Form XIV

[SEE RULE 11(1)(a)]

COMPLAINT TO THE INSPECTOR-CUM-FACILITATOR

To,

The Inspector-cum-Facilitator

(Under The Code on Social Security, 2020)

Sir,

I………………………………………………………..… (Name of the woman) employed

in………………………………………………..…..… (name and full address of the establishment)

or I…….........................................................., (name), a person nominated under section 62 by or

a legal representative of….......................................................… (Name of the woman) employed

in………………………………………..…. (Name and full address of the establishment) having fulfilled

the conditions laid down in the Code on Social Security, 2020 and the Rules thereunder, am entitled to

Rs……..........................being maternity benefit and/ or Rs…................being the medical bonus and/ or

Rs…...........……. being wages for leave due under section 65 but the same has been improperly withheld by

the employer/discharged or dismissed during or on account of her absence from work in accordance with

the provisions of this Chapter VI of Code on Social Security, 2020.

You are therefore requested, to direct the employer to pay the amount to me/ to set aside the

discharge or dismissal done by the employer.

Signature or thumb impression of the Woman/

nominee/ legal representative

Date…………

Signature of an Attester in case the woman/

nominee/ legal representative is

unable to sign and affixes thumb impression.

Full address of the women/nominee/legal representative.