FORM K
[See rule 48]
MEMORANDUM OF AGREEMENT

It is hereby submitted that on the ………..day of………… 19……….. personal injury was ea used 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 whereby it is estimated that he will be prevented from earning more than of his previous/any wage for a period months. The said workman has been in receipt of half- monthly payments which have continued from the………day of .... ...... 19 until the…………… day of……… …………19…………amounting to Rs. ...........in all. The said workmen’s monthly wages are estimated at Rs………… The workman is over the age of l5 years/will reach the age or 15 years on ….…….. ……….. ………… …………
It is further submitted that ………….. the employer of said workman has agreed to pay, and the said workman has agreed to accept, the sum of Rs in full settlement of all and every claim under the Workmen’s Compensation Act, 1023, in respect of all disablement or a temporary nature arising out of the said ,accident, whether now or hereafter to become manifest. It is therefore requested that this memorandum be duly recorded.
Dated ……… ……… ……….. ………..
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 his 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 sun of
Rs…...

 ............................ Workman.
Dated……………..19………….
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 diseases, agreement when workman is under legal disability,-etc.