Form III

[(See rules 32 (1),(2), (3) and (4)]

[For the purpose of Chapter-V]

Nomination/Fresh Nomination/Modification of Nomination

(Strike out the words not applicable)

Sl. No. Details of the employee:

1. Name of employee in full

2. Father‘s/Spouse‘s name

3. Date of Birth (- -/- -/- - - -)

4. Universal Account Number(if available):

5. Sex

6. Religion

7. Whether unmarried/married/widow/widower

8. Department/Branch/Section where employed

9. Post held with Ticket No. or Serial No., if any

10. Date of appointment

11. Date of superannuation

12. Permanent address:

Village:

Post-Office:

Thana:

Sub-Division:

District:

State:

Pin-Code:

E-mail ID:

Mobile Number:

To………………………………………………………………………………………………………

……………..

(Give here name or description of the establishment with full address)

I, Shri/Shrimati/Kumari…………………………………(Name in full here)whose particulars are

given in the statement below, hereby nominate the person(s) mentioned below/ have acquired a family

within the meaning of clause (33) of section 2 of the Code on Social Security, 2020 (36 of 2020) with

effect from the …………………(date here) in the manner indicated below and therefore 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 and direct that the said amount of gratuity shall be paid in

proportion indicated against the name(s) of the nominee(s).

or

I, Shri/Shrimati/Kumari……………………………(Name in full here) whose particulars are given in

the statement below, hereby give notice that the nomination filled by me on date ………… and

recorded under your reference No…………….dated………………. shall stand modified in the

following manner:-

*Strike out unnecessary portion.

Nominee(s)

S.No. Name in full with full Relationship Age of Aadhaar No. of the Proportion by

address of with nominee nominee which

nominee(s) the employee the gratuity will be

shared

1.

2.

3.

So on

DECLARATION

1. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of

clause (33) of section 2 of the Code on Social Security, 2020 (36 of 2020).

2. I hereby declare that I have no family within the meaning of clause (33) of section 2 of the said

Code.

3 (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.

4. I have excluded my husband from my family by a notice dated the……………… to the competent

authority in terms of clause (33) of section 2 of the said Code.

5. Nomination made herein invalidates my previous nomination.

Manner of acquiring a ―Family‖

(Here give details as to how a family was acquired, i.e., whether by marriage or parents being

rendered dependent or through other process like adoption)

Place:

Date:

Signature/Thumb-impression of the Employee

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-III filed by me and duly certified by the

employer.

Date: ………………….

Signature of the Employee