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 India, Ministry of Labor and Employment, New Delhi.
(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)