Form V

[See Rule 19 (3)]

Fresh Nomination

(Strike out the words not applicable)

To………………………………

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

I, Shri/Shrimati …………………………………(Name in full here)whose particulars are

given in the statement 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).

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 (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

competent authority in terms of clause (33) of section 2 of the said Code.

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

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

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 V filed by me and duly certified by the

employer.

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