Form XXXVII (A)

[See rule 80 of the U. P. Social Security Rules, 2026)

Proforma for appeal before the Appellate Authority against Order of assessment or Order imposing penalty

Name and address (permanent) of the establishment.

Name of the employer and address details.

Name and address/ location of place where the building or other

construction is proposed to be carried on.

Name, designation and address of the authorised Person along with

contact details.

Correspondence address for the proposed building or other construction

work.

Nature of proposed construction work.

Date of commencement of work(in case construction has has started).

Date of completion of work.

Duration of work.

Total completed area of construction work.

Total estimated cost of the construction based on the rates of (PWD or

CPWD or RERA or some other rates, as the case may be) along with

documents (original) as per Rule 41.

Total incurred cost of the construction work 13 Total amount of cess

payable.

Total amount of cess payable %age of total incurred cost of the Total cess

construction as notified by Central payable (in the

Government Rs.)

Advance cess paid, along with details (at the time of approval of the

Project or before the commencement of the construction work)

/deduction at source, if any

Details of cess paid (when duration of the proposed construction work is

more than one year)

Sl. No. Year Amount (In Rs.)

15.1 1st Year

15.2 2nd Year

Total amount of the cess paid (Sl. No. 14+ Sl. No. 15)

Amount of outstanding cess (Sl. No. 13 – Sl. No.16)

Proof of payment of outstanding Cess, if any

Amount of overpaid cess, if applicable

Amount of cess assessed by the Assessing Officer

Amount of outstanding cess to be paid by the employer

Amount of penalty for non-payment of cess imposed/ outstanding cess

claimed by the assessing officer.

Ground for appeal with supporting documents

Remarks, if any

Declaration

1. I/We hereby declare that the particulars given above are true to the best of my/our knowledge and belief and I/We hereby declare

that nothing has been concealed or any fact has been mis-represented in the above calculation made by me/us.

2. I/We hereby declare that I/We am/are quite aware of the penal provisions of the Code on Social Security, 2020 and if in future

anything mentioned in the above self-assessment of cess amount, is found to be incorrect or inappropriate or any incidence of hiding

the facts or under calculation of cess amount is found, punitive action may be taken against me/us.

Signature and seal of employer

Name:

Date:

Place:

Mobile Number:

E-mail (if any):

For the use of the Inspector-cum-Facilitator.