Form XIV

[See Rule 59]

NOMINATION/ FRESH NOMINATION/ MODIFICATION OF NOMINATION

(Strike out the words not applicable)

To…………………………………………………………………………………………………

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

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 Code on Social Security, 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………………. shall stand modified in the

following manner

*(Strike out unnecessary portion)

2. 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.

3. I hereby declare that I have no family within the meaning of clause (33) of section 2 of the said

Code.

4. (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.

5. 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.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Sl Name in full with full Relationship with Age of Proportion by which

No. address of nominee(s) the employee nominee the gratuity will be

shared

1.

2.

3.

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).

Statement :

1. Name of employee in full

2. Sex

3. Religion

4. Whether unmarried/married/widow/widower/divorced

5. Department/Branch/Section where employed

6. Post held with Ticket No. or Serial No., if any

7. Date of appointment

8. Permanent address :

Village…………………..........................................................Thana……..……………..............

Sub-division………………...........................Post-Office……….............Pin-code…………........

District………………………..……….................State…………………....................…………..........

E-mail ID…………………………….......... Mobile Number……………………..........

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

Date: Name and address of the establishment or rubber stamp thereof.

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