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Gopal Rai
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Citizen Feedback Form
Form K Application of gratuity by a legal heir

 
[See sub-rule (3) of rule 7]
 
Application of gratuity by a legal heir
 
To
[Give here name or description of the establishment with full address]
Sir/Gentlemen,
I beg to apply for payment of gratuity to which I am entitled under sub-section (1) of section 4 of the Payment of Gratuity Act, 1972 as a legal heir of late …………………… [name of the employee] who was an employee of your establishment and died on the …… without making any nomination. The gratuity is payable on account of the death of the aforesaid employee while in service/ superannuation of the aforesaid employee on the ………………… retirement or resignation of the aforesaid employee on the …………… after completion of ……………… years of service/total disablement of the aforesaid employee due to accident or disease while in service with effect from the ……………… Necessary particulars relating to my claim are given in the statement below:
 

Statement



   
1.
Name of applicant legal heir...........................................................
2.
Address in full of applicant legal heir...........................................................
3.
Marital status of the applicant legal heir (unmarried/married/widow/widower).......................................
4.
Name in full of the employee...........................................................
5.
Relationship of the applicant with the employee...........................................................
6.
Religion of both the applicant and the employee...........................................................
7.
Date of appointment and total period of service of the employee.......................................................
8.
Department/Branch/Section where the employee worked last............................................................
9.
Post last held by the employee with Ticket or Serial No., if any......................................................
10.
Total wages last drawn by the employee...........................................................
11.
Date and cause of termination of service of the employee (death or otherwise)....................................
12.
Date of death of the employee and evidence/witness in support thereof..............................................
13.
Total gratuity payable to the employee...........................................................
14.
Percentage of the gratuity claimed...........................................................
15.
Basis of the claim and evidence/witness in support thereof...........................................................
2.
I declare that the particulars mentioned in the above statement are true and correct to the best of my knowledge and belief.
3.
Payment may please be made in cash/open or crossed bank cheque.
4.
As the amount payable is less than Rupees one thousand, I shall request you to arrange for payment of the sum due to me by Postal Money Order at the address mentioned above, after deducting Postal Money Order commission therefrom.
    Yours faithfully,
Place .......................... Signature/Thumb impression on
Date .......................... of applicant legal hair.
Note:
Strike out the words not applicable.
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Last Updated : 23 Mar,2014
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