INDIVIDUAL APPLICATION
[See sub-sec. (2) of s. 15 of the Payment of Wages Act]

In the Court of the Authority appointed under the Payment of Wages Act (IV of 1936) for	 area……….
Application No………….of 20……..	
Between ABC	
(through a legal practitioner)	                            Applicant
an official of which is a
registered trade union And XYZ		Opposite Party
1. ABC is a person employed in/or the……………….Factory Railway entitled and industrial establishment resides at……………… 	
2. The address of the applicant for the service of all notices and processes is:
XYZ, the opposite party, is the person responsible for the payment of………….his wages under s. 3 of the Act and his address for the service of all notices and processes is:
(1) The applicant's wages have not been paid for the following wage
period(s) (give date). Or
A sum of Rs	has been unlawfully deducted from his wages
of (amount) for the wage period(s) which ended on [give date(s)].
(2) Here give any further claim or explanation.
The applicant estimates the value of the relief sought by him at the
sum of Rupees	
The applicant prays that a direction may be issued under sub-sec. (3)
of s. 15 for—
(a) Payment of his delayed wages as estimated or such greater or lesser amount as the authority may find to be due. Or
Refund of the amount illegally deducted.
(b) Compensation amounting to	
The applicant certifies that the statement of facts contained in this application is to the best of his knowledge and belief accurate.
                                                                              Signature or thumb impression 
                                                                              of the employed person, or legal 
                                                                              practitioner or official of a 
                                                                              registered trade union duly 
                                                                              authorised