1[FORM C)
Application under sub-section (1) of section 17 of the Working Journalists (Conditions of service) and Miscellaneous Provisions Act, 1955
(See rule 36)

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 labour matters)……..(here insert the name of the place where the headquarters of the State Government are situated).
Sir,
I have to state that I Shri/Shrimati/Kumari………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 (Conditions of service) and Miscellaneous Provisions Act, 1955 (45 of 1955).
I further state that I was appointed by Shri………..by an instrument dated……to receive the amount of the gratuity on behalf of Shri/Kumari……………….
I further state that I 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 section 17 of the said Act, and paid to me as early as possible.
*[I have been duly authorised 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………..(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).]
*To be struck out when the payment is claimed by the newspaper employee himself.
Station  ………                                                            Signature of the applicant
Date…………                                                             Address…………………
                                     
ANNEXURES
(Here insert the details of the amount claimed)
1.         Forms C to G ins. by G.S.R. 1320, dated Ist August 1963.