Form XI

[See sub-rule (1), (2), (3), (4), (5) of rule 52]

Nomination/ Fresh nomination/ Modification of nomination for Gratuity

(* strike off whichever is not applicable. )

To,

………………………….

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

I, Shri/Srimati/Kumari....................................... (full name)whose particulars are given in the statement below, hereby

nominate the person(s) mentioned below/ have acquired a family within the meaning of sub-section (33) of section 2 of

the Code with effect from (mention date here) in the manner indicated below and therefore nominate afresh the

person(s) to receive the gratuity payable after my death, and 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).

or

I, Shri/Srimati/Kumari............................................. (full name) whose particulars are given in the

statement below, hereby give notice that the nomination filled by me on date........................ and recorded

under your reference number ………….. dated..................... shall stand modified in the following

manner-

(* strike out whichever is not applicable. )

2. I, hereby certify that the person(s) mentioned is/are member(s) of my family within the meaning of clause (h)

of section 2 of the Payment of Gratuity Act, 1972 or sub-section (33) of section 2 of Code on Social Security,

2020.

3. I hereby declare that I have no family within the meaning of clause (h) of section 2 of the Payment of

Gratuity Act, 1972 or sub-section (33)of section 2 of the Code.

4. I hereby declare that-

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.

5. I have excluded my husband from my family by a notice dated............................. to the Competent

Authority in terms of clause (33) of section 2 of the said code.

7. strike off whichever is not applicable.

8. Nomination made herein invalidates my previous nomination-

NOMINEE(S)

Name in full with Relationship with Age Proportion by which the

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

1 2 3 4

1.

2.

3.

4.

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 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

Village ………………… Thana ………………… Sub-Division ………………… Post

office ……………..… District…………… State ………… Pin code ………… e-

mail id: ……………………………….……….. Mobile number: …………………

Place Signature/thumb-impression

Date of the employee.

Declaration by witness

I............................... hereby declare that the above nomination form has been 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 that 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.

Acknowledgement by the employee

Received the duplicate copy of nomination in Form-XI filed by me and duly certified by the employer .

Date: Signature of the employee.