Form of Individual Application [See sub-section (2) of section 15 of the Payment of Wages Act] In the Court of the Authority appointed under the Payment of Wages Act, 1936 (4 of 1936) for ……………….. area.
Application No. ……….. of …….
Between A.B.C. ………………………………….. Applicant (through a legal practitioner/an official of …………………………….. which is a registered Trade Union.)
And X.Y.Z………………………………………………………opposite party: The applicant states as follows: 1. A.B.C. is a person employed in the/on the factory/railway/industrial establishment entitled and resides at …………………………………….. The address of the applicant for the service of all notices and processes is:
…………………………………………………………………………………
2. X.Y.Z., the opposite party, is the person responsible for the payment of his wages under section 3 of the Act, and his address for the service of all notices and processes is:………………………………………………………………………………….. 3. (1) The applicant’s wages have not been paid for the following wage period ( s)………………………………….(give dates) Or A sum of Rs…………….. has been unlawfully deducted from his wages of amount for the wage-period(s) which ended on ……………… (give dates)
(2) [Here give any further claim or explanation].
4. The applicant estimates the value of the relief sought by him at the sum of Rs……………… 5. The applicant prays that a direction may be issued under sub-section (3) of section 15 for – (a) Payment of delayed wages as estimated or such greater or lesser amount as the Authority may find to be due. Or Refund of the amount illegally deducted. (b) Compensation amounting to ……………………… The Applicant certifies that the statement of facts contained in this application is to the best of his knowledge and belief accurate.
Signature or thumb impression of the employed person, or legal practitioner or official
of a registered trade union duly authorized.
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