FORM XV
[SEE RULE 51 (1)]
DISPLACEMENT AND OUTWARD JOURNEY ALLOWANCE SHEET

Name and address of the Contractor.
Name and address of the Principal Employer.
Name and address of the establishment.
Month and Year.
1. Serial No.
2. Name of the migrant workman
3. Father’s/Husband’s name
4. Permanent home address indicating the State
5. Place and address of residence in home State
6. Designation
7. Rate of wages
8. Wages payable in a month
9. Place of recruitment
10. Place of work with address indicating the State
11. Railway Station/Bus Stand nearest to the place of residence
12. Railway station/Bus Stand nearest to the place of work
13. Date and time of commencement of journey from the place of residence
14. Expected date and time of arrival at the place of work.
15. Details of modes of journeys from the place of residence in the home State to the place of work.
16. Amount of bus fare and/or second-class train fare and/or other journey expenses separately as the modes of journey indicated in column (15)
17. Total of amount indicated in column No. (16)
18. Amount of displacement allowance.
19. Amount of outward journey allowance.
20. Wages for outward journey period.
21. Total amount paid.
22. Date on which paid.
23. Signature or thumb-impression of the migrant workman.
24. Actual date and time of arrival at the place of work.
25. Balance wages for outward journey, if any payable.
26. Date of payment of the balance wages indicated in column (25)
27. Signature of thumb-impression of the migrant workman.
28. Remarks.
NOTE. -Indicate separately different mode of journeys. Entries are to be made against each individual migrant work-man.
Signature of the Contractor or his
Authorised representative.