FORM ‘G’
[SEE SUB-RULE (3) OF RULE 6]
FRESH NOMINATION
To……………………………….
[Give here name or description of the establishment with full Address]
I, Shri/Shrimati…………..[Name in full here] whose particulars are given in the statement below, have acquired a family within the meaning of clause (h) of Section (2) of the Payment of Gratuity Act, 1972……….with effect from the………….[date here]………in the manner indicated below and therefore nominate afresh 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 amount has become payable, or having become payable has not been paid direct that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).
2. I hereby certify the person(s) nominated is a/are member(s) of my family within the meaning of clause (h) of Section 2 of the said Act.
3. (a) My father/mother/parent is/are not dependent on one
(b) My husband’s father/mother/parents is/are not dependent on my husband.
4. 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.
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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3. |
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4. |
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So on. |
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MANNER OF ACQUIRING A ‘FAMILY”
[Here give details as to how a family was acquired, i.e., whether by marriage or parents being rendered dependent or through other process like adoption].
STATEMENT
1. Name of the employee in full.
2. Sex.
3. Religion.
4. Whether unmarried/married/widow/widower.
5. Department/Branch/Section where employed.
6. Post held with Ticket No. or Serial No., if any.
7. Date of appointment.
8. Permanent address.
Village……………Thanna…………Sub-division………………..Post Office
District…………………..State………………….
Place Signature/Thumb impression
Date of the employee.
DECLARATION OF WITNESSES
Fresh nomination signed/ thumb impressed before me.
Name in full and full addresses Signature of witnesses
of 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 the nomination in Form……….filed by me on………… duly certified by the employer.
Date Signature of the employer
