Appendix

FORM OF APPOINTMENT OF BENEFICIARY (NOMINATION)

(Form ‘F’ / ‘G’ / ‘H’ under Payment of Gratuity Rules, Form 40A under Income-tax
Rules)

To To
The Trustees BNP Paribas
BNP Paribas Gratuity Fund

1. In supersession of any or all earlier nomination(s) made by me, I, Mr./Ms.

_______________________________________________ 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 amount has become payable, or having become
payable has not been paid and direct that the said amount of gratuity shall be paid in
proportion indicated against the name(s) of the beneficiary(ies).

2. I hereby certify that the person/s nominated is a / are member/s of my “family” within
the meaning of clause (h) of Section 2 of Payment of Gratuity Act, 1972.
OR
3. I hereby declare that I have no “family” within the meaning of clause (h) of Section 2
of the said Act.

4. (a) Certified that my father / mother / parents / sister(s) / minor brother(s) is / are
dependent upon me.
(b) Certified that my husband’s father / mother / parents is / are dependent upon my
husband.

5. The nominee at Sr. No(s) is / are minor and I hereby appoint Mr. / Ms.
______________________ of (address) ___________________________________
________________________________ to receive the benefits on behalf of the said
minor(s) in the event the amount becomes payable during his / her / their minority.

6. Nomination made herein invalidates my previous nomination(s).

Nominee(s)
Name in full with full Relationship with Age of Proportion by which the
address of nominee(s) the employee nominee gratuity will be shared
(1) (2) (3) (4)
1
2
3
4
 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 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 Witnesses

Nomination signed / thumb impressed before me.

Name in full & full address of witnesses Signature of witnesses:

1………………………………… 1……………………………..

2………………………………… 2……………………………..

Place:
Date:

Certificate by the employer

Certified that the particulars of above nominations have been verified and recorded in
this establishment.
Employer’s Reference No., if any.

Signature of the employer / officer authorized

Date ……… Designation

Name and address of the establishment or rubber-stamp thereof

 Acknowledgement by the employee

Received the duplicate copy of nomination in Form filed by me and duly certified by the
employer.

Date: Signature of the employee

Note: Strike out the words / paragraphs not applicable.

NOTES:

1. Where an Employee Member has a “family” at the time of appointing a

Beneficiary / Nominee, the Nomination should necessarily be made in favour of one or
more Members of his “family” only. Any Nomination made by such Employee in favour of
any other persons not belonging to his “family” shall be invalid.

(“Family” means Member’s (Employee’s) spouse, children or step-children (whether

married or unmarried), dependent parents, dependent parents of member’s spouse,
widow / children of pre-deceased son, if any, sisters and minor brothers).

2. Where an Employee Member does not have a “family” at the time of appointing a
Beneficiary / Nominee, the Nomination may for the time being be made in favour of one
or more other persons. Once such Employee subsequently acquires a “family” (e.g. by
marriage or by parent/s being rendered dependent or by adoption, etc.) the Nomination
made earlier in favour of such other persons not belonging to his “family” shall become
invalid and the Employee will be required to make a fresh appointment in the Form.

3. If a Beneficiary shall at the time of his appointment be a minor or otherwise under

disability to give a legal receipt or discharge to the Trustees the Member must at the
time of such appointment as aforesaid appoint a person who is major and who is
capable of giving a legal receipt or discharge to the Trustees and to whom the benefits
are to be paid for and on behalf of such Beneficiary.

4. An Appointment of Beneficiary / Nominee made by the Member may be changed

at any time, after giving a written notice to the Trustees of his intention to do so i.e. by
filling up a fresh form as given above.

5. The appointment of Beneficiary / Nominee or any change thereof made from time
to time shall take effect to the extent it is valid on the date on which it is received by the
Trustees.

6. If a Nominee predeceases the Member (Employee), the interest of the Nominee

shall terminate and his / her share shall be payable proportionately to such of the
remaining Nominee(s) as survive the Member unless the Member makes a fresh
nomination in the Form.

7. Two witnesses to the signature of the member (not themselves being nominees
or Trustees) should sign in the presence of each other and the member, all being
present at the same time.