Form V

[(See rule 33(2)]

Notice for payment/rejecting claim of gratuity

(Strike out the words not applicable)

To,………………………………………………………………………………………………………

……………………………….

(Name and address of the applicant employee/nominee legal heir)

You are hereby informed that

(a) *as required under sub-clause (ii) of clause (a) of sub-rule (2) of rule 33 of the Social Security

(Central) Rules, 2026, that your claim for payments of gratuity as indicated on your application in

Form-IV under the said rules is not admissible for the reasons stated below:

Reasons (Here specify the reasons); or

(b) *as required under sub-clause (i) of clause (a) of sub-rule (2) of rule 33 the Social Security

(Central) Rules, 2026 that a sum of Rs. ………..(Rupees…………………) is payable to you as

gratuity/as your share of gratuity in terms of nomination made by ………………..on

…………………and……………recorded in this …………………as a legal heir

of………………….an employee of this establishment.

2.*Please call at ……………………..on………………………… (Here specify

place)……………………..(date) at……………….(time) for collecting your payment of

gratuity crossed cheque.

3. Amount payable shall be sent to you through demand draft or shall be credited in your bank

account as desired by you.

4. Brief statement of calculation

a. Date of appointment.

b. Date of termination/superannuation/resignation/ disablement/death.

c. Total period of service of the employee concerned: ………………….years………………..

months.

(d) Wages last drawn:

(e) Proportion of the admissible gratuity payable in terms of nomination/as a legal heir:

(f) Amount payable:

*strike out para, if not applicable

Place:

Date: Signature of the Employer/Authorised Officer.

Name or description of establishment or

rubber stamp thereof.

Copy to:

The Competent Authority.