Form XXIII

{See Rule 66}

Memorandum of agreement in case of temporary disablement

To,

The Competent Authority for Employee’s Compensation,

……………………………….

Sir/Madam,

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 employment in

………………….

The sudden injury has resulted in temporary disablement to the employee whereby it is submitted that he will

be prevented for earning more than of his previous wages for a period of …………………. month. The said

employee has been in receipt of half monthly payment which have continued from the …….. day of …………

20…… until ……….. day of ………… 20…… amounting to rupees ……..... in all. The said employee’s monthly

wages are estimated rupees The employee is over the age of 15 years/ will reach the age of 15 years on ………….

It is further submitted that the employer of the said employee has agreed to pay and the said employee has

agreed to accept the sum of rupess in full settlement of all and every claim under the Code on Social Security, 2020

in respect of all disablement of a temporary nature arising out of the said accident, whether now or hereafter to

become manifest it is therefore requested that this memorandum duly be recorded.

Date: Signature of employer

Witness of employer:

1.

2.

Signature of workmen

Witness of employer:

1.

2.

Note: An application to register an agreement can be presented under signature of one party provided that the

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

Receipt

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

In accordance with the above stated agreement, I have this day received the sum of rupees ………….

Date:

Signature of employee

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

Signature of witness