Form XVII

[See Rule 58]

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 under

sub-rule (7) of rule 55 or sub-rule (8) of rule 57 of Uttar Pradesh Code on Social Security Rules, 2021 for

payment of a sum of Rs................................. as gratuity payable under the Code on Social Security, 2020.

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.

Date:

Place:

Signature/Thumb impression

of applicant.

Note: Strike out the words not applicable.