FORM B
Nomination form for payment of gratuity under section 5 of the Working Journalists (Conditions Of Service) and Miscellaneous Provisions Act, 1955
[See rule 5(5)]

I,…………….. hereby cancel the nomination made by me on the. …………regards the
disposal in the event of my death of the amount of gratuity standing to my credit and hereby nominate the person/s mentioned below to receive the amount of, 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 and direct that the said amount shall be distributed among the said persons in the manner shown below against their names: -

Name and address of the nominees	Nominee’s relationship with the working journalist	Age of nominee	Amount of share of gratuity to be paid to each nominee	Contingencies on the happening of which the nomination shall become invalid
1	2	3	4	5

Date...............                                                                Signature of the working journalist
Certified that above declaration has been signed by ……………………employed in
…………………………………(the name of the newspaper establishment to be given).
Dated…………………                                                 Signature of a responsible official
                                                                                      of the newspaper establishment
Signature of witness …………………              (1) Designation
Dated   ……………..                                      (2) Name and address of the newspaper
Signature of witness……………….                    Establishment…………………..
Dated…………………….