Form XVI

[See Rule 41 (1]

Application by a person authorized by a worker or by the assignee or heir of a deceased

worker under sub-section (1) of section 59 of the Industrial Relations Code, 2020

To

(1) The Secretary to the Government of Arunachal Pradesh, Department of Labour and Employment,.

(2) The Deputy Labour Commissioner.

Sir,

I Shri/Shrimati/Kumari.............have to state that Shri/ShrimatiKumari......................... is/was entitled

to receive from M/s................................. a sum of ` .................(in words) on account

of............................. under the provisions of Chapter IX and X of the Industrial Relations Code, 2020 /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 worker

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 59 of the Industrial Relations Code, 2020, and paid to me as early as possible.

I have been duly authorized in writing by.....................(here insert the name of the worker) to make

this application and to receive the payment of the aforesaid amount due to him.

I am the assignee/heir of the deceased worker and am entitled to receive the payment of the aforesaid

amount due to him.

Station............................ Signature of the authorized person/assignee/heirs

Date……………...............

Address.........................