Form III

(See Rule 43)

SINGLE APPLICATION UNDER SUB-SECTION (5) OF SECTION 45 OF THE CODE

BEFORE THE AUTHORITY APPOINTED UNDER SUB-SECTION (1) OF SECTION 45 OF THE

CODE ON WAGES, 2019 (29 of 2019)

FORAREA………………….

Application No………………………of 20…….

Between ABC and (State the number)……..other……………………. Applicant

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

Address……………………………………………………………………………………

versus

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) of

Shri/M/s………………..(name of the employer) and was/were/has been/ have been 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(1) of the Code of

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 from period(s) from ………. To ……………

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

applicants(s) as per details specified in the annexure appended with this application.

(f) The applicants(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 of

Wages, 2019 for ;

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

actually paid;

(b) Payment of renumeration for the days of rest;

(c) Payment of wages at the overtime rates;

(d) Payment of delayed wages;

(e) Payment of deductions in wages made in contravention of the Code;

(f) Payment of unpaid bonus;

(g) Compensation amounting 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.

Mobile number and Email-id: …………………………….

NOTE:- The applicant(s), if required may append annexures containing details, with this application.

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