Form XVIII

[ See sub-rule(1) of Rule 59 ]

Complaint to the Inspector-cum-Facilitator

The Inspector-cum-Facilitator,

………………………………..

(Under The Code on Social Security, 2020)

Sir,

I, .................... (name of 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 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 there

under, 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.

Date:

Place:

Signature or thumb impression

of the Woman/ nominee/legal representative

Full address of the women/

nominee/legal representative:

Signature of an Attester

(in case the woman/ nominee/ legal representative is unable to sign and affixes thumb impression)