FORM ‘F’

[See s u b -r u le(1 ) of r u le 6 ]

No m in at io n

To……………………………………………………………………………………………………

[Give h ere n a m e or d es cr ip tion of t h e es t a b lis h m en t wit h fu ll a d d res s ]

I, S h r i/ Sh r im a t i/ Ku m a r i…………………wh os e p a r ticu la r s a re given in th e

s t a tem en t b elow,
[Na m e in fu ll h ere]
h ereb y n om in a te t h e p er s on (s ) m en tion ed b elow t o receive th e gr a t u it y p a ya b le
a ft er m y d ea th a s a ls o t h e gr a t u it y s t a n d in g t o m y cred it in th e even t of m y
d ea th b efore t h a t a m ou n t h a s b ecom e p a ya b le, or h a vin g b ecom e p a ya b le h a s
n ot b een p a id a n d d ir ect t h a t t h e s a id a m ou n t of gr a t u it y s h a ll b e p a id in
p r op or tion in d ica ted a ga in s t t h e n a m e(s ) of th e n om in ee(s ).

2. I h ereb y cer tify th a t th e p er s on (s ) m en tion ed is a / a r e m em b er(s ) of m y

fa m ily with in t h e m ea n in g of cla u s e (h ) of s ect ion (2 ) of t h e Pa ym en t of
Gr a t u it y Act , 1 9 7 2 .

3. I h ereb y d ecla re th a t I h a ve n o fa m ily wit h in t h e m ea n in g of cla u s e (h ) of

s ection (2 ) of t h e s a id Act .

4. (a ) My fa t h er / m ot h er / p a ren t s is / a r e n ot d ep en d a n t on m e.

(b ) m y h u s b a n d ’s fa t h er/ m ot h er / p a ren t s is / a r e n ot d ep en d a n t on m y
h u sban d.
5. I h a ve exclu d ed m y h u s b a n d fr om m y fa m ily b y a n ot ice d a te t h e …… to
t h e con t rollin g a u t h or it y in ter m s of t h e p r ovis o t o cla u s e (h ) of s ect ion 2
of t h e s a id Act .

6. Nom in a t ion m a d e h erein in va lid a tes m y p r eviou s n om in a tion .

No m in e e (S )

Na m e in fu ll Rela t ion s h ip Age of n om in ee Pr op or tion b y

with fu ll a d d res s with t h e wh ich th e
of n om in ee(s ) em p loyee gr a t u ity will b e
s h a red
1.
2.
3.
s o on .

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 S t at e m e n t
1. Na m e of em p loyee in fu ll
2. Sex.
3. Religion .
4. Wh et h er u n m a r r ied / m a r r ied / wid ow/ wid ower .
5. Dep a r t m en t / Br a n ch / Section wh ere em p loyed .
6. Pos t h eld with Tick et or S er ia l No., if a n y.
7. Da te of a p p oin t m en t .
8. Per m a n en t a d d res s .

Villa ge… … … … … … ..Th a n a … … … … … … … .S u b -d ivis ion … … … … … … Pos t Office…

Pla ce S ign a tu re/ Th u m b im p r es s ion

Da te of t h e em p loyee

Decla ra tion by w itn es s es

Nom in a t ion s ign ed / th u m b im p res s ed b efore m e.

Na m e in fu ll a n d fu ll S ign a tu re of wit n es s es

1. 1.
2. 2.

Pla ce
Da te

Certif ica te by th e em p loy er

Cer t ified t h a t t h e p a r t icu la r s of t h e a b ove n om in a t ion h a ve b een verified a n d

r ecor d ed in t h is es t a b lis h m en t .

E m p loyer ’s Referen ce No., if a n y

S ign a tu re of t h e em p loyer /
Officer a u th orized

Des ign a t ion

Da te Na m e a n d a d d r es s of t h e
E s t a b lis h m en t or r u b b er s t a m p
t h ereof.

Ack n ow led gem en t by th e em p loy ee

Received th e d u p lica te cop y of n om in a t ion in For m ‘F’ filed b y m e a n d d u ly

cer t ified b y t h e em p loyer .

Da te S ign a tu re of t h e em p loyee

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