FORM V
[See sub-rule (2) of rule 5]
Registered
From:
(Give here name and complete address of the employer)
To
(Give here name and address of the Prescribed Authority)
Subject: Deposit of amounts of undisbursed wages
Sir,
As required under sub-rule (1) read with sub-rule (2) of rule 5 of the Payment of Undisbursed Wages (Mines) Rules, 1989, enclose the crossed demand draft bearing number…….dated………..
(mention the number) (mention the date)
for Rs………………………..……(Rupees…………….)
(mention the amount in figures)
…………………………………………………………………………………
(mention the amount in words)
drawn in your favour obtained from…………………………………………..
(mention the name and address of banks)
…………………………………………………………The above-mentioned amounts represent all amounts payable as wages to persons employed in…………………. I
(mention the name and address of the mine)
which remained undisbursed because either no nomination had, been made by the employed person(s) or for any reasons such amount could not be paid to the respective nominee(s) of the employed person (s). The relevant details are furnished thereunder.
(1) Particulars of the relevant wage period. …………………
(mention the details of the 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-1)
(mention the number of such cases)
(3) Number of cases in which all amounts
payable to an employed person as wages
by the employed person (s) (O details as
per Annexure-II).
………………………
mention the number of such case
Yours faithfully,
Signature of the employer/
officer authorised.
Designation:
Name and address of the mine
or rubber stamp thereof.
Place:
Date:
ANNEXURE-I |
SI. No. |
Name and address of the employee |
Wage-period |
Amount payable |
1 |
2 |
3 |
4 |
1 |
|
|
|
2 |
|
|
|
3 |
|
|
|
TOTAL
ANNEXURE-II
SI. No. |
Name and address of the employee |
Name and address of the nominee |
Wage period |
Amount payable |
1 |
2 |
3 |
4 |
5 |
|
|
|
|
|
TOTAL |
