Memorandum of Agreement

It is hereby submitted that on the………………day of………………20…….personal injury was caused to…………… residing at………………by accident arising out of and in the course of employment in………………The said injury has resulted in temporary disablement to the said workman, who is at present in receipt of wages amounting to Rs ……..per month / no wages The said workman’s monthly wages prior to the accident are estimated at Rs . ………. The workman is subject to a legal disability by reason of ……………………………

It is further submitted that………………the employer of the workman has agreed to pay and………………on behalf of the said workman has agreed to accept half­ monthly payments at the rate of Rs . ………………for the period of the said temporary disablement. This agreement is subject to the condition that the amount of the , half­ monthly payments may be varied in accordance with the provisions of the said Act on account of an alteration in the earnings of the said workman during disablement. It is further stipulated that all rights of commutation under section 7 of the said Act are unaffected by this agreement. It is, therefore, requested that this memorandum be duly recorded.

Dated………………20………………
Signature of Employer ……………………………………………………………………………………
Witness ……………………………………………………………………………………………………….
Signature of workman ……………………………………………………………………………………
Witness ………………………………………………………………………………………………………

Note.‑An application to register an agreement can be presented under the signature of one party, provided that the other party has agreed to the terms. But both signatures should be appended, whenever possible.

Receipt (to be filled in when the money has actually been paid).

In accordance with the above agreement, I have this day received the sum of
Rs ……………….
Dated ………………..20………… ……………………..Workman

The money has been paid and this receipt signed in my presence.
…………….Witness

Note.‑This form may be varied to suit special cases, e.g., injury by occupational disease, etc