Form II

[See rule 41]

[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)………other……………………………………………. Applicant

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

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

And

XYZ…………………………………………………………………………………

Address………………………

The application 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) T he 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, with this

application.