Social Security Form XXVIII: applicant certificate supporting compensation claim

Applicant’s truth certificate accompanying the Form XXVII compensation application, rather than a medical certificate.

See rule 59(2) · Social Security (Central) Rules, 2026 · Central-sphere scope

Download and read the completed example

Fictional Ravi Kumar temporary-injury compensation case, with the specific application, certificate, jurisdictional notice or accident-report fields shown separately. No medical finding or authority act is executed.

Fictional, unsigned completed illustration. It demonstrates this form’s fields; it is not a filed return, medical opinion, official order or proof of an actual transaction.

When and how this form is used

Rule 59(2) prescribes the applicant’s certificate about the Form XXVII particulars. It does not certify diagnosis, disablement percentage or medical fitness.

The completed fields

Applicant certificate

Prescribed field / section	Completed fictional entry
To / application	Competent authority for employee compensation; hypothetical Ravi Kumar v Sahyadri Illustration Services Pvt Ltd, Form XXVII dated 20 October 2026
Applicant / address	Ravi Kumar, 5 Example Street, New Delhi 110001
Declaration	Particulars stated in the linked fictional Form XXVII are true to the applicant’s assumed knowledge and belief; nothing material concealed or misrepresented
Date / applicant execution	New Delhi, 20 October 2026; Signature / seal / certification not executed; typed name is an illustration only

Supporting records and reconciliation

Linked actual Form XXVII and the documents supporting its factual statements; medical evidence remains separate.

Official source and version

Official Gazette, Social Security (Central) Rules, 2026; Form XXVIII; PDF pages 257–258

Download the official source pages containing this form. Adjacent prescribed forms can share a source page; use the heading and rule identified above.

The Central Rules have their stated jurisdiction. The corresponding appropriate-government rules and any later amendment must match the real establishment and event.

Practical questions

Can I submit the sample as my own completed form?

No. Replace the fictional facts with accurate records, use the competent filing or record-keeping route described above and complete genuine signatures or certifications where required.

What makes the example specific to this form?

It verifies the applicant’s own compensation-claim particulars; the word “certificate” does not make it a medical or authority-issued finding.