The Uttar Pradesh Code on Social Security Rules, 2026
Form XXXIII
Official text
Open in the official PDF (p. 165)
Tables and forms lose their layout when extracted; the PDF is the authoritative version.
[See sub-rule (2) of Rule 72]
Application for Commutation
To,
The Competent Authority for Employee’s Compensation
……………………………………..
………………….…................................................. Applicant residing at)
Versus
……………………….................................................... (Opposite Party residing at)
Sir/Madam,
It is hereby submitted that –
1. The applicant/opposite party has been in receipt of half monthly payment from to
in respect of temporary disablement by accident arising out of and in the course
of his employment.
2. The application is desirous that the right to receive half-monthly payments should be redeemed.
3. It is submitted that-
monthly a. The opposite party is unwilling to agree to the redemption of the right to receive half- payments.
b. The parties have been unable to agree regarding the sum for which the right to receive half- monthly payment should
be redeemed.
You are therefore requested to pass order—
a. directing that the right to receive half-monthly payments should be redeemed.
b. Fixing a sum for the redemption of the right to receive half-monthly payments.
Date: _20
Place:
Signature/ Thumb impression
of the applicant
o strikeout of the clauses which are not applicable.