Form XV

APPEAL

[SEE RULE 11 (2) (b)]

To,

The Authority,

(Appointed under the Code on Social Security, 2020)

…………………………………………… (Address)

Sir,

I…………, the undersigned, woman employee of…………… (name and full address of the

establishment)

*Feel aggrieved by the order of Inspector-cum-Facilitator under subsection (2) of section 72

for the reasons attached hereto, prefer this appeal under sub-section (2) of section68 and request that

the said employer be ordered to pay the above-mentioned amount to me. A copy of the order of Inspector-

cum-Facilitator cum Facilitator in this behalf is enclosed;

or

*Shri…................................…,Inspector-cum-Facilitator, having directed under subsection (2)

of section 72 to pay the maternity benefit or other amount being…................……(Nature of amount) to

which…...............................…… (Name of the woman) is said to been titled/to set aside my discharge or

dismissal during or on account of absence from work in accordance with the provisions of this Chapter V

of the Code on Social Security, 2020(Strikeout unnecessary portion).

I prefer this appeal under sub-section (3) of section 72. In view of the facts mentioned in the

memorandum attached hereto and other documents filed herewith, it is submitted that the woman is not

entitled to the maternity benefit or the said amount and hence the order of the Inspector-cum-Facilitator in

the copy of which is enclosed, maybe set aside.

*Strike out unnecessary portions.

Signature or thumb impression of the Women

/Aggrieved person

Date………

Signature of an Attester in case the woman is

not able to sign and affixes thumb impression.

Full address of the nominee/legal representative