Form V

[See Rule 7 (2) (3) ]

Fresh Nomination

To

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Give her name or description of the establishment with full address.)

I, sri/srimati…………………………………………..(name in full here) whose particulars

are given in the statement below, have acquired a family within the meaning of sub-section

(33) of section 2 of the code ……………….. with effect from the ……………….. (date

here)…………………………….. in the matter indicated below and therefore nominate a

fresh 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, 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 the person(s) nominated is a/are member(s) of my family within the

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

3.(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.

4. I have excluded my husband from my family by a notice, dated the …………………… to

the controlling authority in terms of the proviso to sub-section (33) of section 2 of the code.

NOMINEE(S)

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

address of nominee(s) employee the gratuity will be

shared

1 2 3 4

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 The Employee.

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

Date signature/thumb-impression of the employee

Declaration by witnesses

Fresh nomination signed/thum-impressed before me.

Name in full and full address of witness.

Signature of witnesses

1. 1.

2. 2.

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.

Designation .

Name and address of the establishment

Or rubber stamp thereof.

Acknowledgment by the employee

Received the duplicate copy of the nomination in form's’ filed by me on……………… ,

duly certified by the employer.

Date signature of the employee

Note-Strike out the words and paragraphs not applicable.