Form XXXIX

[ See sub-rule (1) of Rule 91 ]

Notice to the employer for an offence committed under the provisions of the Code for the first time for

compounding of offences unde r sub-section (1) of section 138

Notice No.. …………….. Date: ………………..

On the basis of records and documents produced before me, the undersigned has reasons to believe

that you, being the employer of the establishment......................(Registration No.............), have committed an

offence for the violation of provision of the Code or the Schemes or the Rules or the Regulations framed

thereunder as per the details given below:-

PART-I

Name of the person:

Name and Address of the establishment:

Registration No. of the establishment:

Particulars of the offence:

Provisions of the Code/Scheme/ Rules/Regulations under which the offence is committed:

Compounding amount required to be paid towards composition of the offence:

Name and details of account for depositing the amount specified in serial no. 6:

PART-II

In view of the above, you have an option to pay the entire amount mentioned in serial no. 6 in Part-I

within fifteen days from the date of issue of this notice and return the application duly filled in Part - III of this

notice.

In case the said amount is not paid within the specified time, necessary action for filing of prosecution

shall be initiated without giving any further opportunity in this regard.

Date:

Place:

(Signature)

(Name and Designation of

Compounding Officer)

To:

……………………….(Employer/Establishment)

…………………………(Name and registration number)

………………………....(Address)

PART-III

[ See sub rule (2) of rule 91 ]

Application under sub-section (4) of section 138 for compounding of offence

Ref: Notice No............ Date: ……………….

The undersigned has deposited the entire amount as specified in serial 6 of Part-I and the details of payment are

given below with a request to compound the offences mentioned in Part-I.

8. Details of the compounding amount deposited (Copy of electronically generated receipt to be attached):

9. Details of the prosecution, if filed for the violation of above-mentioned offences may be given:

10. Whether the offence is first offence or the applicant had committed any other offence prior to this offence, if

committed, then, full details of the offence:

11. Any other information which the applicant desires to provide:

Signature of the applicant

(Name and Designation)

Date:

Place:

To:

………………....(Compounding Officer)

………………….(Name of the Office)