Form XIV

[See clause (a) of sub-rule (1) of rule 55]

Application for Direction for payment of gratuity

Before the Competent Authority for Chapter V under the Code on Social Security, 2020

Application No: Date:

BETWEEN

(Name in full of the applicant with full address)

AND

(Name in full of the employer 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.............................. and

employee of the above- mentioned employer, and is entitled to payment of gratuity under section 53 of the Code on

Social Security, 2020 on account of his own/aforesaid employee's superannuation on.................................(date)/his

own retirement/ aforesaid employees resignation on.......................(date) completion of.....................years of continuous

service/his own/aforesaid employees' total disablement with effect from..........(date) due to accident/disease/ death of

aforesaid employee on...................

2. The applicant submitted an application under rule 53 of the Uttar Pradesh Code on Social Security Rules,

2021 on the but the above-mentioned employer refused to entertain it/issued a notice dated the...................... under

clause (b) and (e) of sub-rule (2) of rule 53, offering an amount of gratuity which is less than my due/issued a

notice dated......................... the under sub-clause (ii) of clause (a) of sub-rule (2) of rule 53, rejecting my eligibility to

payment of gratuity. The duplicate copy of the said notice is enclosed.

3. The applicant submits that there is a dispute on the matter (specify the dispute).

4. The applicant furnishes the necessary particulars in the annexure hereto and prays that the Competent

Authority may be pleased to determine the amount of gratuity payable to the petitioner and direct the above-mentioned

employer to pay the same to the petitioner.

The applicant declares that the particulars furnished in the annexure hereto are true and correct to the

best of his knowledge and belief.

Date:

Signature/ Thumb impression

of the applicant