Form XVIII B

(SEE RULE 17)

MEMORANDUM OF AGREEMENT

It is hereby submitted that on the ................... day of ............ 20...... personal injury was caused to

....................... residing at by accident arising out of and in the course of his employment in ................. The

said injury has resulted in death to the said workman.

The said employee’s monthly wages are estimated at Rs. ........................ The employee is over the age of 15

years / will reach the age of 15 years on ............................

The said employee has, prior to the date of the agreement, received the following

payments, namely: --

Rs. ..................... on ................ Rs. ......................... on ................................

Rs.................... on ............................. Rs. .............. on ...............................

Rs. ......................on .................. Rs ......................... on ................................

It is further submitted that the employer of the said employee has agreed to pay, and dependent (s) of the

said employee has agreed to accept, the sum of Rs. .................... in full settlement of all and every claim

under the Code on Social Security, 2020 in receipt of death stated above. It is, therefore, requested that

this memorandum be duly recorded.

Dated ..........................20.........

Signature of employer

Witness

Witness

Signature or dependant(s)

Note- Application to register an agreement can be presented under the signature of one party: provided

that the other party has agreed to the terms. But both signatures should be appended, whenever possible.

Receipt (to be filled in when the money has actually been paid)

In accordance with the above agreement, I have this day received the sum of

Rs...................

Dated ...................20.... .

Dependant(s)

The money has been paid and this receipt signed in my presence.

Witness