Form IV

[See Rule 19 (1), (2)]

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 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/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.

Nominee(s)

Proportion by

Name in full with full Relationship with Age of which

S.No.

address of nominee(s) the employee nominee the gratuity will

be shared

1.

2.

3.

So on

Statement

1. Name of 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…………………………

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-IV filed by me and duly certified by the

employer.

Date: …………………. Signature of the Employee