Form XII

[See clause (a) of sub-rule (1) of rule 53]

Application of Gratuity By An Employee/Nominee/ Legal Heir

To,

……………………………

[Give the name or description of the establishment with full

address] Sir/Madam,

I,…………………........(name of employee/nominee/legal heir)/nominee of Lat

e ………………(name of employee)/as a legal heir of …………. (name of employee), beg to

apply for payment of gratuity to which I am entitled under sub-section (1) of section 53 of the

Code on Social Security, 2020 on account-

a. of my superannuation/retirement/resignation after completion of not less than five years of

continuous service/total disablement due to accident/ total disablement due to disease/ on

termination of contract period under fixed term employment with effect from the; or

b. death of the aforesaid employee while in service/ superannuation on................. after completion of

…........... years of service/ total disablement of the aforesaid employee due to accident or disease

while in service with effect from the.................... ; or

c. death of aforesaid employee of your establishment while in service/

superannuation on ………..(date) without making any nomination after

completion of....................... years of service/ total disablement of the aforesaid employee due to

accident or disease while in service with effect from ………..

Necessary particulars relating to my appointment in the establishment/details of applicant

(nominee/ legal heir) are given in the statement below:

STATEMENT

1. Name of employee, in full (if the gratuity is claimed by employee):

a. Marital status of employee (unmarried/ married/ widow/ widower):

b. Full address of employee:

c. I was rendered totally disabled as a result of accident/ disease from: (give the details of

the nature of disease or accident with evidence):

Or

2. Name of nominee/ legal heir (if the gratuity is claimed by nominee/ legal heir):

a. Name of employee:

b. Marital status of nominee/ legal heir (unmarried/ married/ widow/ widower):

c. Relationship of nominee/ legal heir with the employee:

d. Full address of nominee/ legal heir:

e. Date of death and proof of death of the employee:

f. Reference number of recorded nomination, if available:

3. Department /Branch/Section where last employed:

4. Post held with Ticket No. or Serial No. if any:

5. Date of appointment:

6. Date and cause of termination of service:

7. Total period of service of the employee:

8. Amount of wages last drawn by the employee:.

9. Total gratuity payable to the employee/ share of gratuity claimed by a nominee/ legal heir:

10. Payment may please be made by crossed bank cheque/ credit in my bank account number

……….IFSC code ……Name of the Bank ……………… branch ………

Place:

Date:

Yours faithfully,

Signature/ Thumb

impression of the

applicant/employee.