FORM ‘D’
[SEE SUB-RULE (1) OF RULE 5]
NOTICE FOR EXCLUDING HUSBAND FROM FAMILY

From……………………………………….
1. Name of the female employee.
2. Name or description of establishment where employed.
3. Post held with Ticket or Serial No., if any.
4. Department/Branch/Section where employed.
5. Permanent address.
Take notice that I, Shrimati…………….desire to exclude my husband Shri………………….from my family for the purposes of the Payment of Gratuity Act, 1972.
Place                                                            Signature/Thumb impression         
Date                                               of the employee.

DECLARATION BY WITNESSES

The above notice was signed/thumb impressed before me.
           
Name in full and full                                                      Signature of witnesses.
address of witnesses.
1.                                                                                 1.
2.                                                                                 2.
Place
Date
To
The Controlling Authority.
(Through the employer)
[Name and address of the employer here]

FOR USE BY THE EMPLOYER
RECEIVED AND RECORDED IN THIS ESTABLISHMENT.

                                                                           Signature of the employer or an
Date                                                             officer authorised in this behalf
                                                                           by the employer
Reference No.
To
1. ………………. (Employee)
2. The Controlling Authority.