Form II

[See Sub-Rule (1) of Rule 40]

[SINGLE APLICATION UNDER SUB-SECTION (5) OF SECTION 45]

BEFORE THE AUTHORITY APPOINTED UNDER SUB SECTION (1) OF SECTION

45 OF THE CODE ON WAGES, 2019 (29 OF 2019)

FOR…………. (AREA)………

Application No………………………………………….of 20……

Between ABC and (State the number) ……… others………………. Applicant(s)

(Through employees concerned or registered trade union or Inspector- cum-

Facilitator)

Address……………………………………………………………………………….

And

XYZ……………………………………………………………………… Respondents.

Address………………………

The applicant states as follows:

(1) The applicant(s) whose name(s) appear in the attached schedule

was/were/has/have been employed from ……………to……..

as……………...(category) in…………….(establishment) Shri/M/s………engaged

in………….(nature of work) which is/are covered by the Code on Wages, 2019.

(2) The opponent(s) is/are the employer(s) within the meaning of section 2(l) of

the Code on Wages, 2019.

(3) (a)The applicant(s) has/ have been paid wages at less than the minimum

rates of wages fixed for their category (categories) of employment(s) under

the Code by Rs…. …………..Per day for the period(s)

from………………………to……… ……………….

(b) The applicant(s) has/ have not been paid wages at Rs…………….. Per day

for the weekly days of rest from………………..to…

(c) The applicant(s) has/ have not been paid wages at overtime rate(s) for the

period from…………………..to….

(d) The applicant(s) has/have not been paid wages for period from

………………to……….

(e)Deductions have been made which are in contravention of the Code, from

the wage(s) of the applicant(s) as per details specified in the annexure

appended with this application.

(f) The applicant(s) has/have not been paid minimum bonus for the

accounting year ……………..

(4) The applicant(s) estimate(s) the value of relief sought by him/ them on each

amount as under:

(a) Rs…….

(b) Rs…….

(c) Rs…….

Total Rs…….

(5) The applicant(s), therefore, pray(s) that a direction may be issued under

section 45(2) of the Code on Wages, 2019 for;

(a) payment of the difference between the wages payable under the Code and

the wages actually paid,

(b) payment of remuneration for the days of rest

(c) payment of wages at the overtime rates,

(d) compensation amounting to Rs………………………

(6) The applicant(s) do hereby solemnly declare(s) that the facts stated in this

application are true to the best of his/their knowledge, belief and information.

Dated………….

Signature or thumb-impression of the

employed person(s), or

official of a registered trade union duly authorized or

Inspector- cum-Facilitator.

Note: The applicant(s), if required, may append annexures containing details, to

this application.