Form XVI — See Rule 40

Form- XVI
                                                            (See rule 40)

               (COMPLAINT UNDER SECTION 91 OF THE INDUSTRIAL RELATIONS CODE, 2020)

Before the Conciliation officer/ Arbitrator/ Tribunal or, National Industrial Tribunal ----,

In the matter of:...................................Reference No…………………………………….

                     A......................                 Complainant(s);
                                               Versus

                     B......................              Opposite Party(ies).
Address:

The petitioner(s) begs/beg to complain that the Opposite Party(ies) has/have been guilty of a contravention of the
provisions of section 90 of the Industrial Relations Code, 2020 as shown below:

(Here set out briefly the particulars showing the manner in which the alleged contravention has taken place and the
grounds on which the order or act of the
management is challenged.)

The complainant(s) accordingly prays/pray that the Conciliation officer/ Arbitrator/ Industrial Tribunal or National
Industrial Tribunal may be pleased to decide the complaint set out above and pass such order or orders thereon as it may
deem fit and proper.

The number of copies of the complaint and its annexure required under rule 40 are submitted herewith.

Dated this............day of............20..... Signature of the complainant(s)

Verification

I do solemnly declare that what is stated in paragraph.......... above is true to my knowledge and that what is stated in
paragraphs........ above is stated upon information received and believed by me to be true. This verification is signed by
me at.................... on ............day of....................20.....................

                                                                                                                  Signature
                                                                 or thumb impression of the person verifying_____________.

                                                                                          [F. No. S-11025/01/2026-IR(PL)]
                                                                                           DEEPIKA KACHHAL, Jt. Secy.

               Uploaded by Dte. of Printing at Government of India Press, Ring Road, Mayapuri, New Delhi-110064
                                 and Published by the Controller of Publications, Delhi-110054.   KUMER CHAND
                                                                                                           Digitally signed by KUMER
                                                                                                           CHAND MEENA

                                                                                                 MEENA     Date: 2026.05.08 14:23:38
                                                                                                           +05'30'