Minister
Gopal Rai
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Result
Citizen Feedback Form
Form F Nomination

Nomination
To …………………………………………………………………………………………………………………………………………………
[Give here name or description of the establishment with full address]
I. Shri/Shrimati/Kumari…………………......................whose particulars are given in the statement below,
  [Name in full here]
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 nominee(s).
2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of clause (h) of section (2) of the 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/parents is/are not dependant on me.
(b) my husband's father/mother/parents is/are not dependant on my husband.
5. I have excluded my husband from my family by a notice dated the ………………… to the Controlling Authority in terms of the proviso to clause (h) of section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Nominee(s)
Name in full with full address of nominee(s) Relationship with the employee Age of nominee Proportion by which the gratuity will be shared
1.      
2.      
3.      
so. on.      
 

 

 

   
Statement
1. Name of 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
  of the employee
Date  
Declaration by witnesses
Nomination signed/thumb impressed before me.
Name in full and full Signature of witnesses.
address of witnesses.  
1. 1.
2. 2.
Place  
Date  
Certificate by the employer
Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any.
    Signature of the employer/
officer authorised
    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
Signature of the employee
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Last Updated : 23 Mar,2014
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