Form IV

[(See rule 33(1)]

Application for gratuity by an Employee/nominee/legal heir

(Strike out the words not applicable)

To,……………………………………………………………………………

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

Sir/Madam,

I, ………………………..(name of employee/nominee/legal heir) /nominee of

late…………………………….(Name of the employee)/ as a legal heir of

late…………………………….(Name of the employee), want to apply for payment of gratuity to

which I am entitled under sub-section (1) of section 53 of the Code on Social Security, 2020 (36 of

2020) on account of-

(a) my superannuation/retirement/resignation after completion of not less than five years of

continuous service/total disablement due to accident/total disablement due to disease/ on

termination of contract period under fixed term employment with effect from

the…………………..or;

(b)death of the aforesaid employee while in service/superannuation on………………after

completion of…………..years of service/total disablement of the aforesaid employee due to

accident or disease while in service with effect from the………… or;

(c)death of aforesaid employee of your establishment while in service/superannuation

on…………………………(date) without making any nomination after completion of

……………..years of service/total disablement of the aforesaid employee due to accident or

disease while in service with effect from……………………

Necessary particulars relating to my appointment are given in the statement below.

1. Name of employee in full, (if the gratuity is claimed by an employee)

a. Marital status of employee(unmarried/married/widow/widower)

b. Address in full of employee

or

2. Name of nominee/legal heir, (if the gratuity is claimed by nominee/legal heir)

a. Name of Employee

b. Marital status of nominee/legal heir(unmarried/married/widow/widower)

c. Relationship of nominee/legal heir with the employee

d. Address in full of nominee/legal heir

e. Date of death and proof of death of the employee

f. Reference No. of recorded nomination, if available

3. Department/Branch/Section where last employed

4. Post held by employee.

5. Date of appointment.

6. Date and cause of termination of service

7. Date of Death

8. Total period of service of the employee

9. Total wages last drawn by the employee.

10. Total gratuity payable to the employee/ share of gratuity claimed by a nominee/legal heir.

11. Payment may please be made by crossed bank cheque/credit in my bank account no…...

Yours faithfully,

Signature/Thumb-impression of the

applicant employee/nominee/legal heir.

Place:

Date: