DECLARATION FOR CLAIMING THE GRATUITY FUND

I, NITIN PATIDAR, SO / WO / DO MOHAN PATIDAR declare that before joining Aditya Birla Sun Life Insurance Company Limited, I had received an aggregate
amount of Rs. ______ (in words Rupees ______________________________________________________) towards payment of Gratuity as nontaxable and Rs.
____________________ if claimed as taxable on which Rs. ________________________ is deducted as income Tax.

OR

I, NITIN PATIDAR, SO/WO/DO MOHAN PATIDAR declare that before joining Aditya Birla Sun Life Insurance Company Limited, I had not received any amount
towards payment of Gratuity from any employer as I was not eligible for the same.

The above declaration is true and in case anything contrary to the same is even found, I shall be liable for appropriate legal action

Name of the employee: NITIN PATIDAR

Employee code:

Signature of the employee

 Establishment or rubber stamp there of ________________________________________

NOMINATION

Form F

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

To

Aditya Birla Sun Life Insurance Company Limited

_________________________________________
_________________________________________
_________________________________________
_________________________________________

1. I Shri/Shrimathi/Kumari NITIN PATIDAR Whose particulars are given in 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 every month of my death before the 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
nominee (s).

2. I here by certify that the person(s) mentioned is/are a member(s) of my family within the meaning of Clauses(h) of Section 2 of Payment of Gratuity
Act 1972.

3. I hereby declare that I have no family within the meaning of Clause(h) of Section 2 of the said Act.

4. (a) My father/mother/parent is/are not dependent on me.

5. I have excluded my husband from my family by a notice dated the .................................. to the Controlling authority in terms of the provision to
Clause(h) of Section 2 of the said Act.

6. Nomination made here in invalidates my previous nomination.

S Relationship with the Proportion by which the Gratuity will

Name in full with full address of nominee(s) DOB
No. employee be shared
Pratik patidar,
22-02-
1 240 Near gayatri temple Kanadiya Indore Indore Madhya Pradesh Siblings (Brother/Sister) 100%
2000
(MP) India 452016
 Statement

1. Name of the employee in full: NITIN PATIDAR

2. Sex: Male

3. Religion: Hindu

4. Whether unmarried/married/widow/widower: Unmarried

5. Department/Branch/Section where employed: Business Development Manager

6. Post held with ticket No. or serial No., if any:

7. Date of appointment:

8. Permanent Address:

Village kanadia Thana _______________ Post office ____________________________ District Indore state Madhya Pradesh (MP)

Place: .,Near gaytri mandir,kanadia,kanadia,Indore,Madhya Pradesh (MP),452016,India

Signature/Thumb-impression of the employee

Date: 10-11-2023 15:11

Declaration by witnesses
Nomination signed/thumb-impressed before me name in full and full address of witness. Signature of Witnesses
1._________________________________________________ _________________________________________________
_________________________________________________
2._________________________________________________ _________________________________________________
_________________________________________________

Place: ________________________

Date: ________________________

Certificate by the employer

Certified that the particulars of the above nominations have been verified and recorded in the establishment,
Employer's reference No., if any Signature of the employer/officer authorized
designation
Date:
Name and address of the establishment or rubber stamp thereof

Acknowledgement by the employee received the duplicate copy of nomination in form 'F' filed by me and duly certified by the employer.

Date: 10-11-2023 15:11

Signature of the employee