FORM F

[See sub-rule (1) of Rule 6]

PAYMENT OF GRATUITY NOMINATION

To
Head HRD

1. I,below,
Shri/ Shrimati/ Kumari Aaush whose particulars are given in the statement
hereby nominate the person(s) mentiohed below to receive the gratuity payable after death as also the
gratuity standing to my credit in the even of my death before the amount has become payable, or having become
payable has nor been paid and direct that the said amount of Gratuity shall be paid in proportion indicated
against the name(s) of the nominee(s).
2. Ihere by certify that the person(s) mentioned is/are my wife/childre/lawfully adopted child/dependant
parents/husband.
3. I hereby declare that | have no family and should I acquire family hereafter the appointment of
Beneficiary/Nominee should be deemed as cancelled.
4. a) My father/mother/parents/sister(s)/ minor brother(s) is/are not dependant on me.
b) My husband's father/mother/parents is/are not dependent on my husband. to the controlling authority in terms
1. Ihave excluded my husband from my family by a notice dated
of the proviso to clause (h) of section 2 of the said Act.
2. Nomination made herein invalidates my previous nomination.
Nominee(s)
Relationship with Age of Nominee/s Proportion of which the
S. No.Name in full with full gratuity (total benefits) will be
address of Nominee/ the employee Beneficiary/ies
shared by each Nominee
Beneficiary/ies
Beneficiary

Ajg singh (oo.

1.
|A-bolA kyichan fathes
2. Vinas ew delhi-l) oo&e

3.

4.

I give below the particulars about myself:

1 Full Name: Ankush Singh
2 Sex. male
3 Religion Hlndu
4 Father's Name:
Husband's Name:
Ajay Singh
5
(For married women only)
Martial Status: Single
(Whether married, unmarried, widow or widower)
Department/Branch/Section where employed
8 Post held with ticket or SerialNo. if any
9. Date of birth: -03-2002
Date of appointment: 22-02-2024
10.
11. Permanent Address: A-bolA Rishan Vihar New dehi_loo&6

PlaceDelhi Signature/ thkmb-impression

Date 22-02 2024. of the employee
 DECLARATION BY WITNESSES

Nomination signed/thumb-impressed before me.

Address Signature
S.No. Name

1
H-16 Rs han ihr
New dal ) -)1096
2 H-72 kxithan Vihay
Riya. New delhi lob &6

Place: pelh
Date:
22-02-2024

CERTIFICATE BY THE EMPLOYER

been signed by Shri/Shrimati
Certified that the above appointment of Beneficiary Nominee has been
before me after he/she has read the entries, the entries have
Beneficiary/Nominee is recorded under the Scheme on
read to him/her by me and that the said appointment of

Signature of employer/
Employer's reference No., if any
Officer authorized Designation
Date:

NOTE:

Beneficiary/Nominee, the Nomination

1 Where an Employee Member has a family at the time of appointing a
Employee in favour of any
should be made in favour of Member of his family only. Any Nomination made by such
other persons not belonging to his family shall be invalid. time, after giving a
2 An Appointment of Beneficiary/Nominee made by the Member may be changed at any
written notice to the Employer of his intention to do so. If the Nominee predeceases the Member
his estate.
(Employee), the interest of the Nominee shall revert to the member (Employee) or
from time to time shall take effect to the
3 The appointment of Beneficiary/Nominee or any change thereof made
Employer.
extent to the extent it is valid on the date on which it is received by the
be deemed to consist of:
4 For the purpose of the Scheme, "Family", in relation to employee, shall dependent parents
()ln case of a male employee, himself, his wife, his children, whether or unmarried, her if any.
predeceased son,
and the dependent parents of herhusband and the widow and children of her
married or unmarried, her
(ii)lncase of a female employee, herself, her husband, her children whether
widow and children of her
dependent parents and the dependent parents of her husband and the
predeceased son, if any.
within ninety days of acquiring a
1 An employee who has no family at the time of making a nomination shall,
family, submit in the manner specified in sub rule (1), a fresh nomination, as
required under sub section (4) of
Section 6, in duplicate in Form'G' to the employer.