FORM A
[See rule 6 (1)]
DEPOSIT OF COMPENSATION FOR FATAL ACCIDENT
(Section 8 (1) of the Workmen’s Compensation Act, 1923)

Compensation amounting to Rs is hereby presented for deposit in respect of injuries resulting in the death of the workman, whose particulars are given below, which occurred on
Name ……….. ……… ………..
Father’s Name ……… ……….. …………..
(Husband’s name in case of married woman and widow.)
Cast ……….. ………… ……….. …………..
Local address………………………….
Permanent address ……… ……… ……… …… ………
His/ Her monthly wages are estimated at Rs………….He/ She was over/ under the
 age of 15 years at the time of his her/her death.
2. The said workman had, prior to the date of his/her death, received the following payments, namely:
            Rs ……….      On ………      Rs ……….   on
            Rs ……….      On ………      Rs ………    on
            Rs ……….      On ………      Rs ………    on
Amounting in all to Rs………………..
3. An advance of Rs has been made on account of compensation to…………….being
4. *I do not desire to be made a party to the proceedings for distribution of distribution of aforesaid compensation.
Dated ………………..19…………
……. …….. …….. …….. ………     Employer
*.An employer desiring to be made a party to the proceedings should strike out the word so not”.