Rule Form XIII Form XIII

FORM -- XIII-A [See rule 39(1)(a)]

Complaint to the Inspector-cum-Facilitator

To,

The Inspector-cum-Facilitator (under the Code on Social Security, 2020)

Sir, I...... (Name of woman employee) employed in...... (name and full address of the

establishment) or I......, (name), a person nominated under section 62 by or a legal representative of......(name of woman employee) employed in.......(name and full address of the establishment) having fulfilled the conditions laid down in the Code on Social Security, 2020(36 of 2020) and the rules framed thereunder, am entitled to Rs...... being maternity benefit and/ or Rs...... being the medical bonus and/ or Rs.......... being wages for leave due under section 65 but the same has been improperly withheld by the employer/discharged or dismissed during or on account of my/her absence from work in accordance with the provisions of Chapter VI of Code on Social Security, 2020(36 of 2020).

You are, therefore, requested to direct the employer to pay the amount to me and/or to set aside the discharge or dismissal done by the employer.

Place............. Signature or thumb impression of the Woman employee/ Date............ nominee/ legal representative

Signature of an Attester in case the woman employee/ nominee/ legal representative is

unable to sign and affixes thumb impression. Full address of the woman employee/nominee/legal representative.

FORM-XIII-B

To,

The Appellate AuthorityDefined in rule 2(c): Appellate authority means in Central sphere, the Central Government or the authority specified by the Central Government under sub section (8) of section 56 or in State sphere, an officer, senior in rank to the Assessing Officer for the purposes of section 105, appointed by the State Government, as the case may be; ...,

(Appointed under the Code on Social Security, 2020) ...................................................(Address)

Sir,

I........., the undersigned, woman employee/her legal heir/her representative or employer/his representative of......... (name and full address of the establishment) aggrieved by the order of Inspector-cum-Facilitator Shri........ hereby prefer this Appeal under sub-section (3) of section 72 in view of the facts mentioned in the memorandum and other documents filed herewith.

*Denial by his order under sub-section (2) of section 72, the maternity benefit or other amount ......... (Nature of amount) to which......... (Name of woman employee) is entitled and/or refused to set aside discharge or dismissal of ........ (Name of woman employee) during or on account of absence from work in accordance with the provisions of Chapter VI of the Code on Social Security, 2020(36 of 2020)(Strike out unnecessary portion).

*It is submitted that the ........... (Name of woman employee) is not entitled to the maternity benefit or the said amount and/or rightly discharged or dismissed hence the order of the Inspector-cum-Facilitator may be set aside. *Strike out unnecessary portion.

Signature or thumb impression of the Woman employee/Aggrieved person/Employer

Place............. Date.........

............................................................................. Signature of an Attester in case the woman employee is not able to sign and affixes thumb impression. Full address of the nominee/legal representative