FORM C
Application under sub-sec. (1) of Sec. 17 of the Working Journalists and Other Newspaper
Employees (Conditions of Service) and Miscellaneous Provisions Act, 1955
To
The Secretary to the Government of ……………(here insert the name of the State
Government) Department of………………..(here insert the name of the Department which deals
with the labour mattetrs)………………………………(here insert the name of the place where the
headquarters of the State Government are situated).
Sir,
I have to state that I Shri/Smt/Km………………………………son/ widow/ daughter of
…………………….a working journalist, was entitled to receive from ……………….(here insert
the name and address of the newspaper establishment) a sum of Rs…………… on account of
……………………..(here insert gratuity, wages, etc. as the case may be), payable under the
Working Journalists and Other Newspaper Employees (Conditions of Service) and Miscellaneous
Provisions Act, 1955(XLV of 1955).
I further state that I was appointed by Shri ………………………..by an instrument, dated
………………….to receive amount of the gratuity on behalf of Shri/Km
……………………………….
I further state that I have served the said newspaper establishment with a demand notice by
registered post on………………… for the said amount which the said newspaper establishment has
neither paid nor offered to pay to me even though 15 days have since lapsed. The details of the
amount due are mentioned in the statement hereto annexed.
I request that the said sum may kindly be recovered from the said newspaper establishment
under Sec. 17 of the said Act, and paid tome as early possible.
1 Ins. by G.S.R. 1320 , dated the 1st August, 1963
*[ I have been duly authorized in writing by …………………….(here insert the name of the
newspaper employee) to make this application and to receive the payment of the aforesaid amount
due to him.
*[I am a member of the family of late……………………….(here insert the name of the
deceased newspaper employee), being his……………………..(here insert the relationship) and am
entitled to receive the payment of the aforesaid amount due to late ………………………….(here
insert the name of the deceased newspaper employee].
Station…………
Signature of the applicant …..
Dated………. Address……….
*To be struck out when the payment is claimed by the newspaper employee himself.
ANNEXURE
[*Here insert the details of the amount claimed]
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