Form XXV

(See ru le 66)

Memorandum of agreement

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 said injury has resulted in temporary disablement to the said employee, who is at present in the

receipt of wages amounting to rupees...................................................................................................per month.

The said employee monthly wages prior to the accident are estimated at rupees …………..

The workmen is subject to a legal disability by reason of …………………………….....................

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

employee has agreed to accept half-monthly payments at the rate of the period of the said temporary disablement.

This agreement is subject to the condition that the amount of half-monthly payments may be varied in accordance

with the provisions of the Code on account of an alteration in the earnings of the said employee during

disablement. It is further stipulated that all rights of commutation under sub-section (3) of section 93 of the Code

are unaffected by this agreement.

It is, therefore requested that this memorandum duly be recorded.

Date:

Signature of employer

Witness of employer:

1.

2.

Signature of workmen

To,

The Career Centre

.........................

NOTE :–

1. This return is to be rendered to the Career Centre (Regional) within 30 days after the end of the

financial year concerned by establishments/employers vide their obligation under the Code on Social

Security, 2020 (Chapter XIII-Employment Information and Monitoring).

The main purpose in obtaining the information from employers is to know (i) the

vacancies/employment opportunities available; (ii) type of personnel who are in short supply; and

(iii) furure job opportunities for providing vocational guidance to the jobseekers and connecting

them with the employers. This is helpful in ascertaining the skill needs also. Employers too will be

able to call on the Career Centre for getting suitable candidates as per their requirements.

Witness of employee:

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