Form IV

[See Rule 7 (2)]

Nomination

To

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

(Name in full here)

I, Shri/Shrimati/Kumari.......................................whose particulars are given in the

statement below, hereby nominate 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).

2. I, hereby certify that the person (s) mentioned is a/are member (s) of my family

within the meaning sub section (33) of section 2 of the code.

3. I hereby declare that I have no family within the meaning of sub-section (33) of

Section 2 of the 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.

NOMINEE(S)

__________________________________________________________________________

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

address of the employee nominee the gratuity will be

nominee(s) shared

___________________________________________________________ _______________

1 2 3 4

__________________________________________________________________________

1.

2.

3.

4.

so on

_________________________________________________________________

STATEMENT

1. Name of The Employee in full.

2. Sex.

3. Religion.

4. Whether unmarried/married/widow/widower.

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, District State

Place signature/thumb-impression

Date of the employee.

Declaration by witness

Nomination signed/thumb-impressed before me

Name in full and full address

Of witness signature of witness

1. 1.

2. 2.

Certificate by the employer

Certified that the particulars that of the above nomination have been verified and recorded in

the establishment. Employer’s reference no., If any.

Signature of the employer/officer authorized

Designation

Date name and the address of the establishment

Or rubber stamp there of.

Acknowledgment by the employee

Received the duplicate copy of nomination in form ‘f’ filed by me and duty certified by the

employer.

Date signature of the employee.

Note-Strike out the words and paragraphs not applicable.