FORM I





APPEAL UNDER SECTION 7-I OF THE EMPLOYEES' PROVIDENT FUNDS AND MISCELLANEOUS PROVISIONS ACT, 1952 (Rule 4)



Title of the case:-

APPEAL

INDEX

Sl No.

Description of documents relied

Page No.

Signature of the Applicant

For use in Tribunal's office

Date of filing or

Date of Receipt by post

Registration No.

Signature for Registrar IN THE EMPLOYEES' PROVIDENT FUNDS APPELLATE TRIBUNAL BETWEEN A. B. APPELLANT and C. D. RESPONDENT

Details of appeal

1. Particulars of the appellant:

(i) Name of the appellant

(ii) Office address

(iii) Address for service of notices

2. Particulars of the respondent:-

(i) Name of the respondent

(ii) Office address

(iii) Address for service of notices.

3. Particulars of the order/ notification against which appeal is made:

The appeal is against the following order/ notification:-

(i) Order/ notification No. with reference to Annexure

(ii) Date

(iii) Passed by

(iv) Subject in brief

4. Jurisdiction of the Tribunal-

The appellant declares that the subject-matter of the order against which he wants redressal is within the jurisdiction of the Tribunal.

5. Limitation-

The appellant further declares that the appeal is within the limitation prescribed in section 7-I of the Employees' Provident Funds and Miscellaneous Provisions Act, 1952.

6. Facts of the case-

The facts of the case are as given below:-

(Give here a concise statement of facts in a chronological order, each paragraph containing as nearly as possible a separate issue, fact or otherwise.)

7. Details of the remedies exhausted-

The appellant declares that he has availed of all the remedies available to him under the Act.

(Give here chronologically the details of representations made and the outcome of such representation with reference to the Annexure numbers.)

8. Matters not previously filed or pending with any other court-

The appellant further declares that he had not previously filed any appeal, writ petition or suit regarding the matter in respect of which this appeal has been made, before any court of law or any other authority or any other Bench of the Tribunal and or any such appeal, writ petition or suit is pending before any of them.

In case the appellant had previously filed any appeal, writ petition or suit, the stage at which it is pending and if decided, the gist of the decision should be given with reference to the Annexure.

9. Relief(s) sought-

In view of the facts mentioned in para 6 above the appellant prays for the following relief(s):-

[Specify below the relief(s) sought explaining the ground for relief(s) and the legal provisions (if any) relied upon.]

10. Interim order, if any prayed for- Pending final decision on the appeal, the appellant seeks issue of the following interim order.

(Give here the nature of the interim order prayed for with reasons.)

11. In the event of appeal being sent by registered post, it may be stated whether the appellant desires to have oral hearing at the admission stage and if so, he shall attach a self addressed post card/ inland letter, at which intimation regarding the date of hearing could be sent to him.

12. Particulars of bank draft/ postal order in respect of the appeal fee:-

(1) Name of the bank on which drawn.

(2) Demand draft no.

(Or)

(1) Number of Indian postal order

(2) Name of the issuing post office

(3) Date of issue of postal order

(4) Post office at which payable

13. List of enclosures-

1. 4.

2. 5.

3. 6. VERIFICATION

I..................(Name of the appellant), s/o, d/o, w/o.....…… age ……….working as…............in the office of.............resident of...........do hereby verify that the contents of paras......…..to.................are true to my personal knowledge and paras …..........to …...........believed to be true on legal advice and that I have not suppressed any material fact.

Signature of the appellant.

Date:

Place:

To

The Registrar