FORM ‘E’
[SEE SUB-RULE (2) OF THE RULE 5]
NOTICE OF WITHDRAWAL OF NOTICE FOR EXCLUDING HUSBAND FROM FAMILY

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………………….hereby withdraw the notice………….dated whereby I exclude my husband Shri…………….from my family for the purposes of the Payment of Gratuity Act, 1972. The earlier notice was recorded under your reference No…………dated.
Place                                                                        Signature/Thumb impression
Date                                                                         of the employee.

DECLARATION OF WITNESSES

The above notice of withdrawal 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,
(Though the employer)
[Name and address of the employer]

FOR USE BY THE EMPLOYER
RECEIVED AND RECORDED IN THIS ESTABLISHMENT.
           
Reference No.                                                     Signature of the employer or
                                                                                    Officer authorised.
Date                                                                    Seal or rubber stamp of the                                                                                                                    establishment.
To
1…………………(Employee)
2. The Controlling Authority.