Form XVII,

[See rule 41]

Application by a person authorised 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 / Principal Secretary / Additional Chief Secretary to the Government of

Bihar, Labour Resources and Migrant Workers Welfare Department.

(2) The Deputy Labour Commissioner ....................... (here insert the name of the region).

Sir,

I Shri/Shrimati/Kumari.............................................................have to state that

Shri/ShrimatiKumari............................................................is/was entitled to receive from

M/s.....................................................a sum of Rs.........................(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 authorised 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.

or

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.........................