FORM ‘J’ (See Rule 12) To _________________ _________________ Sir, Shri,___________________, Inspector having directed under sub-section (2) of Section 17 to pay the maternity benefit or other amount, being _____________- (nature of amount) to which ________________ (name of woman) is said to be entitled, I prefer this appeal under sub-section (3) of Section 17, In view of the facts mentioned in the memorandum attached hereto and other documents filed herewith it is submitted that the woman is not entitled to the maternity benefit or the said amount and hence the decision of the Inspector in this behalf, copy of which is enclosed, may be set aside. Dated____________ Signature of the aggrieved person Full Address_______________. ---------------------
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