Form V

[SEE RULE 7(2)(3)]

FRESH NOMINATION

To

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

I, Shri/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).

1. 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.

1. (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.

2. 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)

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

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 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 WITNESSES

Fresh nomination signed/thumb-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.