[Rule 62(2)]

Application by a person who is an assignee or heir of a deceased workman under sub-section

(2) of section 33C of the Industrial Disputes Act, 1947

Before the Central Government Labor Court at _______________________________ ________________________ Applicant (s)

________________________ Employer

I / We am / are the assignee(s) of the deceased workman and am / are entitled to make an application on his behalf.Shri _______________ former workman of M/s. of ___________ is entitled to receive from the said M/s _________________ the money / benefits mentioned in the statement hereto annexed.

It is prayed that the Court be pleased to determine the amount / amounts due to the deceased workman. 

Address of workman

Signature or thumb- impression of the applicant (s)

Address of the applicant (s)

Station ______________

Date ________________

ANNEXURE

(Set out the details of the money due or the benefits accrued together with the case for the admissibility)