Form XIX

[ See sub-rule (2) of Rule 60 ]

Appeal before Appellate Authority under Chapter VI of the Code

To,

The Appellate Authority,

(Appointed under Chapter VI of the Code on Social Security , 2020)

..................................................... (Address)

Sir,

I, .................., the undersigned, woman employee of (name and full address of the establishment) –

1. *Feel aggrieved by the order of Inspector-cum-Facilitator under sub-section (2) of section 72 for the

reasons attached hereto, prefer this appeal under sub-section (2) of section 68 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 in this behalf is enclosed; or

2. *Shri.................................. , Inspector-cum-Facilitator, having directed under sub-section (2) of section 72

to pay the maternity benefit or other amount being …………….......... (Nature of amount) to which (Name

of woman) is said to be entitled/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.

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 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, may be set aside.

*Strike out unnecessary portion.

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)