FORM ‘F’
[SEE SUB-RULE (1) OF RULE 6]
NOMINATION
To…………………………………………………………
[Give here name or description of the establishment with full address] I, Shri/Shrimati/ Kumari…………
[Name in full here]
Whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that and direct that ‘he said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of clause (h) of Section (2) of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause(h) of Section (2) of the said Act.
4. (a) My father/mother/parents is/are not dependent on me.
(b) My husband’s father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the ..............................to the Controlling Authority in terms of the proviso to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
NOMINEE(S)
Name in full with full address of nominee(s) |
Relationship with the employee |
Age of nominee |
Proportion by which the gratuity will be shared |
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2. |
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3. |
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4. |
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So on. |
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STATEMENT
1. Name of employee in full.
2. Sex.
3. Religion.
4. Whether unmarried/married/widow/widower.
5. Department/Branch/Section where employed.
6. Post held with Ticket or Serial No., if any.
7. Date of appointment.
8. Permanent address.
Village………………Thana……………..Sub-division………………Post Office
District…………….State…………………..
Place Signature/Thumb impression
Date of the employee
DECLARATION BY WITHNESS
Nomination signed/thumb impressed before me.
DECLARATION OF WITNESSES
Name in full and full address of Signature of witnesses witnesses.
1. 1.
2. 2.
Place
Date
CERTIFICATE BY THE EMPLOYER
Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer’s Reference No., if any.
Signature of the employer/
Officer authorised
Designation.
Date Name and address of the
Establishment or rubber stamp thereof.
ACKNOWLEDGEMENT BY THE EMPLOYEE
Received the duplicate copy of nomination in Form ‘F’ filed by me and duly certified by the employer.
Date Signature of the employee
