FORM XI
(See rule 24)
[Return to he sent by the contractor to the authorities specified under Explanation below sub-section (2) of section 12 of Inter-State Migrant Workmen (Regulation of employment and Conditions of service) Act, 1979.
1. Name and address of the Contractor.
2. Name and address of the sub-contractor through whom recruitment has been made.
3. Name and address of the establishment.
4. Name and address of the Principal Employer.
5. Name of the State in which the place of work is located.
6. Name of the State in which recruitment was made.
Serial No. |
Name of migrant workman |
Father’s/Husbands name |
Sex |
Designation Age |
Age |
1 |
2 |
3 |
4 |
5 |
6 |
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Permanent home address indicating the State |
Place and address of residence in home State |
Date of employment |
Date on which ceased to be employed |
Total days worked |
7 |
8 |
9 |
10 |
11 |
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Details of rates of wages and other allowances paid. |
Amount of displacement allowances paid. |
Amount of outward journey allowances wages for outward journey paid. |
Amount or return journey allowances and wages for return journey paid |
Total wages paid. |
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Details of compensation and other allowances. |
Amount of deducations, if any. |
Amount of advance, if any paid. |
Amount of advance, if any recoverd. |
Remarks |
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DECLARATION
I/We herby declare that all wages, other dues including displacement allowance, outward return journeys allowances and wages for journeys period payable to migrant workman/workmen named above and employed by me/us have been paid by me/us to him/them.
Place:
Date:
Signature of the Contractor or his
authorised representative
Submitted to
(1)………………….
(Specified authority in the State in which migrant workman/workmen is/are employed).
(2).................................
(Specified authority in the State in which migrant workman/workmen has/have been recruited.)
Copy forwarded to
........................................
(The Principal Employer)
Signature of the Contractor or his
Authorised representative.
Date:
NOTE: In case where migrant workmen concerned have been recruited from more than one State, separate returns shall be submitted in respect of each such State.
