Industrial Disputes (Central) Rules, 1957
Application by a person authorized by a workman or by the assignee or heir of a deceased workman under sub-section (1) of section 33C of the Industrial Disputes Act, 1947
(i) The Secretary
to the Govt. of
(ii) The Regional Labor Commissioner (Central),_______________ (Name of the region)
I Sh. / Smt. / Kumari __________________ have to state that Sh. / Smt. / Kumari ____________________ is/was entitled to receive from M/s. ___________________ a sum of Rs. ___________________ on account of ________________________ under the provisions of Chapter V-A / Chapter V-B of the Industrial Disputes Act, 1947 / in terms of the award dated the _____________________ given by _______________ in terms of the settlement dated the _________________ arrived at between the said M/s __________ and their workmen through __________________________ the duly elected representatives.
I further state that I served the management with a demand notice by registered post on __________ for the said amount which the management has neither paid nor offered to pay to me even though a fortnight has since elapsed. The details of the amount have been mentioned in the statement hereto annexed.
I request that the said sum may kindly be recovered from the management under sub-section (1) of section 33C of the Industrial Disputes Act, 1947, and paid to me as early as possible.
I have been duly authorized in writing by __________________________ (name of the workman) to make this application and to receive the payment of the aforesaid amount due to him.
I am the assignee / heir of the deceased workman and am entitled to receive the payment of the aforesaid amount due to him.
Station ___________________ Signature of the applicant ________
(Indicate the details of the amount claimed)