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).

1. 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.

2. I hereby declare that I have no 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.

NOMINEE (S)

Proportion by which

Name in full with full Relationship with the

Age of Nominee the gratuity will be

address of nominee employee

shared

1 2 3 4

1.

2.

3.

4.

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

Place:

Date:

Signature/thumb-impression

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 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 thereof.

Acknowledgment by the employee

Received the duplicate copy of nomination in form ‘F’ filed by me and duly certified by the employer.

Date

Signature of the Employee.

Note-Strikeout the words and paragraphs not applicable.