[Give here name or description of the establishment with full Address] I, Shri/Shrimati [Name in full here] whose particulars are given in the statement below, have acquired a family within the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972 with effect from the [date here] in the manner indicated below and therefor nominate afresh 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 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 the person(s) nominated is a/are member(s) of my family within the meaning of clause (h) of section 2 of the said Act. 3. (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. 4. I have excluded my husband from my family by a notice dated to the controlling authority in terms of the proviso to clause (h) of section 2 of the said Act. Nominee(s) Manner of acquiring a “family” [Here give details as to how a family was acquired, i.e., whether by marriage or parents being rendered dependant or through other process like adoption]. Statement 1. Name of the employee in full. 2. Sex. 3. Religion. 4. Whether unmarried/married/widow/widower. 5. DepartmentlBranch/Section where employed. 6. Post held with Ticket No. or Serial No., if any. 7. Date of appointment. 8. Permanent address. Village Thana Subdivision Post Office District State Place Signature/Thumb impression Date of the employee. Name in full with full address of nominee(s) Relationship with the employee Age of nominee Proportion by which the gratuity will be shared 2. 3. 4. so on. Declaration by witnesses Fresh nomination signed/thumb impressed before me. Name in full and full Signature of witnesses. addresses 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 employeri officer authorised Designation Date Name and address of the establishment or rubber stamp thereof. Acknowledgement by the employee Received the duplicate copy of the nomination in Form filed by me on duly certified by the employer. Date Signature of the employer
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