Annexure to Form XIV

1. Name in full of applicant with full address:

2. Basis of claim (Death/Superannuation/Retirement/Resignation/Disablement of Employee/Completion of

contract period under Fixed Term Employment):

3. Name and address in full of the employee:

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

5. Name and address in full of the employer:

6. Department/Branch/Section where the employee was last employed (if known):

7. Post held by the employee with Ticket or Sl. No., if any (if known):

8. Date of appointment of the employee (if known):

9. Date and cause of termination of service of the employee (Superannuation / retirement /resignation

/disablement / death/Completion of contract period under Fixed Term Employment):

10. Total period of service by the employee:

11. Wages last drawn by the employee:

12. If the employee is dead, date and cause thereof:

13. Evidence/witness in support of death of the employee:

14. If a nominee, No. and date of recording of nomination with the employer:

15. Evidence/witness in support of being a legal heir if a legal heir:

16. Total gratuity payable to the employee (if known):

17. Percentage of gratuity payable to the applicant as nominee/legal heir:

18. Amount of gratuity claimed by the applicant:

Date:

Place:

Signature/ Thumb impression

of the applicant