FORM V
[See sub-rule (2) of rule 6]
REGISTERED POST

From:
(Give here name and complete address of the employer)
To
(Give here name, designation and complete address of the Prescribed Authority)
Sub:     Deposit of amounts of undisbursed wages
Sir,
As required under sub-rule (1) read with sub-rule (2) of rule 6 of the Payment of Undisbursed Wages (Air Transport Services) Rules, 1988. 1 enclose the crossed
Demand draft bearing No………..Dated ………..
(Mention the number) (Mention the date)
For Rs …………………………..                (Rupees…………………)
(Mention ,the amount in figures) (Mention the amounts in words)
drawn in your favour obtained from ……………..(mention the name and address of the bank)
The above mentioned amounts represent all amounts payable as wages to persons employed in (mention the name and address of the establishment) which remained undisbursed because either no nomination had been made by the employed persons or for any reasons such amounts could not be paid to the respective nominee(s) of the employed person(s). The relevant details are furnished hereunder:
1. Particulars of the relevant wage period ……………
(mention the details of wage period)
2. Number of cases in which all amounts payable to an employed person as wages, remained undisbursed for want of nomination (details as per Annexure-l)-,
...................................... . (mention the number of such cases)
3. Number of cases in which all amount& payable to an employed person as wages could not be paid to person(s) nominated by employed person(s) (details as per annexure-11);
...................................... (mention the number of such cases)
Yours faithfully,
(Signature of the employer/
Officer authorised.]
Designation
Name and address of the
establishment or rubber
stamp thereof.
Place………….
Date……………                    
ANNEXUREI

Sl. No.	Name and address of the employee	Wage Period	Amount Payable
1	2	3	4

1.
2.
3.
etc.
Total
ANNEX'URE-II

Sl. No.	Name and address of the employee	Name and address of the nominee	Wage Period	Amount Payable
1	2	3	4	5

Total