Form II

[(See Clause (a) (b) (c) of Sub-Rule (1) of Rule 19]

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)

I,…………………………..……………………………………………………………..(name of

employee/nominee/legal heir) /nominee of late…………………………….(Name of

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

employee), beg 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 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: