Form I

[(See Sub-Rule (1), (2), (3) and (4) of Rule-18]

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. Universal Account Number (if

available):

3. Sex

4. Religion

5. Whether unmarried/ married/

widow/ widower

6. Department/ Branch/ Section

were employed

7. Post held with Ticket No. or Serial

No., if any

8. Date of appointment

9. Permanent address:

Village:

Post-Office:

Thana:

Sub-Division:

District:

State:

Pin-Code:

E-mail ID:

Mobile Number:

Part-I

(for the purpose of Gratuity)

To

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

Sir/Madam,

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............shallst and Modified in the following manner: -

*Strike out unnecessary portion.

Nominee(s)

S. Name in full with Relationship Age of Proportion by which the

No. full address of with the nominee gratuity will be Shared

nominee(s) employee

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 here in 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

Name and address of the establishment or rubber stamp thereof.

Date:

Acknowledgement by the Employee

Received the duplicate copy of nomination in Form-I filed by me and duly certified

by the employer.

Date: ………………….

Signature of the Employee