Form III

[(See Sub-Rule (2) (a) (i) (ii) (b) (d) of Rule 19]

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 19of the

Code on Social Security (Andhra Pradesh) Rules, 2026, that your claim for

payments of gratuity as indicated on your application in Form-III 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 19the

Code on Social Security (Andhra Pradesh) Rules, 2026that 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/authorized officer.

Name or description of establishment or

rubber stamp thereof.

Copy to: The Competent Authority in case of denial of gratuity.

Copy also to: Deputy Commissioner of Labour/Joint Commissioner of Labour.