FORM K4
RECOVERY OF DUES
[Rule 62(2)]
Application by a person who is an assignee or heir of a deceased workman under sub-section
(2) of section 33C of the Industrial Disputes Act, 1947

Before the Central Government Labour Court at _______________________________
________________________ Applicant (s)
________________________ Employer
I/We am/are the assignee(s) of the deceased workman and am/are entitled to make an application on his behalf. Shri _______________ former workman of M/s. of ___________ is entitled to receive from the said M/s _________________ the money/benefits mentioned in the statement hereto annexed.
It is prayed that the Court be pleased to determine the amount/amounts due to the deceased workman.
Address of workman
Signature or thumb- impression of the applicant (s)
Address of the applicant (s)
Station ______________
Date ________________
ANNEXURE
(Set out the details of the money due or the benefits accrued together with the case for the admissibility)