Form K3 Rule 62(2)

APPLICATION FOR DETERMINATION OF AMOUNT DUE FROM AN EMPLOYER TO A WORKER

Application under sub-section (2) of Section 33-C of the Industrial Disputes Act, 1947

Before the Central Government Labour Court at ……………………..

Between

• Name of the applicant(s)…………………….
• Name of the employer………………………..

The petitioner, …………………… a workman of M/s …………………… of ……………………….. The petitioners undersigned, workman of ………………… is/are entitled to receive form the said M/s ……………… the money/benefit mentioned in
the statement hereto annexed.

It is prayed that the Court be pleased to determine the amount/amounts due to the petitioner(s).

Signature or thumb impression(s) of the applicant(s)		Address(es)
1.
2.
3.
4.

Station: ……………

Date: ………………

ANNEXURE

……………………………………………………………………………………………....

(Herein set out the details of the money due or the benefits accrued together
with the case for their admissibility).