Form XVI

[See Rule 60(2)]

NOTICE FOR PAYMENT/ REJECTING CLAIM OF GRATUITY

(Strike out the words not applicable)

To,…………………………………………………………………………………………………

(Name and address of the applicant employee/nominee legal heir).

1. You are hereby informed that

(a) *as required under sub-clause (ii) of clause (a) of sub-rule (2) of rule 60 of the Code on

Social Security (State) Rules, 2021, that your claim for payments of gratuity as indicated on

your application in Form-XV 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 60 of the Code on

Social Security (State) Rules, 2021 that 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/authorised officer.

Name or description of establishment or rubber stamp thereof.

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