Rule Form VI Form VI
- Chapter
- Annexures · Forms and Appendices
- Text as on
- As notified 08 May 2026
FORM-VI [(See rule 33(4)]
Application for Direction 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 concerned with full address)
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.............................. and employee of the above-mentioned employer, and is entitled to payment of gratuity under section 53 of the Code on Social Security, 2020 (36 of 2020) on account of his own/aforesaid employee's superannuation on.................................(date)/his own retirement/aforesaid employees' resignation on.......................(date) completion of.....................years of continuous service/his own/aforesaid employees' total disablement with effect from ......................(date)due to accident/disease death of aforesaid employee on...................
2. The applicant submitted an application under rule........................ of the Social Security
(Central) Rules, 2026 on the ...................but the above-mentioned employer refused to entertain it/issued a notice dated the................ under clause .............of sub-rule of rule ...................offering an amount of gratuity which is less than my due/issued a notice dated the
.................... under clause............. of sub-rule............of rule................... rejecting my eligibility to payment of gratuity. The duplicate copy of the said notice is enclosed.
3. The applicant submits that there is a dispute on the matter (specify the dispute).
4. The applicant furnishes the necessary particulars in the annexure hereto and prays that the
Competent Authority may be pleased to determine the amount of gratuity payable to the applicant and direct the above-mentioned employer to pay the same to the applicant.
5. The applicant declares that the particulars furnished in the annexure hereto are true and correct to
the best of his knowledge and belief.
Place: Date:
Signature/Thumb impression of the applicant.
ANNEXURE
1. Name in full of applicant with full address
2. Basis of claim (Death/Superannuation/Retirement/Resignation/Disablement of Employee/Completion of contract period under Fixed Term Employment)
3. Name and address in full of the employee
4. Marital status of the employee (unmarried/married/widow/widower)
5. Name and address in full of the employer
6. Department/Branch/Section where the employee was last employed (if known)
7. Post held by the employee with Ticket or Sl. No., if any (if known)
8. Date of appointment of the employee (if known)
9. Date and cause of termination of service of the employee (Superannuation / retirement / resignation /disablement / death/Completion of contract period under fixed term employment)
10. Total period of service by the employee
11. Wages last drawn by the employee
12. If the employee is dead, date and cause thereof
13. Evidence/witness in support of death of the employee
14. If a nominee, No. and date of recording of nomination with the employer
15. Evidence/witness in support of being a legal heir, if a legal heir
16. Total gratuity payable to the employee (if known)
17. Percentage of gratuity payable to the applicant as nominee/legal heir
18. Amount of gratuity claimed by the applicant
Place: Signature/Thumb-impression of the applicant Date: