Annexure to Form VI

1. Name in full of applicant with full address

2. Basis of claim (Death/Superannuation/Retirement/Resignation/Disablement of

Employee/Completion of contract period under Fixed Term Employment)

3. Name and address in full of the employee

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

5. Name and address in full of the employer

6. Department/Branch/Section where the employee was last employed (if known)

7. Post held by the employee with Ticket or Sl. No., if any (if known)

8. Date of appointment of the employee (if known)

9. Date and cause of termination of service of the employee (Superannuation / retirement / resignation

/disablement / death/Completion of contract period under fixed term employment)

10. Total period of service by the employee

11. Wages last drawn by the employee

12. If the employee is dead, date and cause thereof

13. Evidence/witness in support of death of the employee

14. If a nominee, No. and date of recording of nomination with the employer

15. Evidence/witness in support of being a legal heir, if a legal heir

16. Total gratuity payable to the employee (if known)

17. Percentage of gratuity payable to the applicant as nominee/legal heir

18. Amount of gratuity claimed by the applicant

Place:

Date: Signature/Thumb-impression of the applicant