Rule Form IX Form IX
- Chapter
- Annexures · Forms and Appendices
- Text as on
- As notified 08 May 2026
FORM -- IX [(See rule 33 (13)]
Application for Recovery of Gratuity
Before the Competent Authority for Chapter V under the Code on Social Security, 2020
Application No. Date
BETWEEN
(Name in full of the applicant with full address)
AND
(Name in full of the employer/Trust/Insurer concerned with full address)
1. The applicant is an employee of the above-mentioned employer/a nominee of
late........................ an employee of the above mentioned employer/a legal heir of late ..................an employee of the above-mentioned employer, and you were pleased to direct the said employer in your notice dated the .............................under sub-rule (11) or sub-rule (12) of rule 33 of Social Security (Central) Rules, 2026for payment of a sum of Rs....................... as gratuity payable under the Code on Social Security, 2020 (36 of 2020).
2. The applicant submits that the said employer failed to pay the said amount of gratuity to me as
directed by you although I approached him for payment.
3. The applicant therefore prays that a certificate may be issued under section 129 for recovery of the
said sum of Rs. ............................due to me as gratuity in terms of your direction.
Signature/Thumb-impression of applicant.
Place: Date: Note.--Strike out the words not applicable.