Form XII

[See Sub-rule (3) of Rule 40]

NOMINATION FORM

To

……………………………

……………………………

……………………………

[Give here name or description of the establishment with full address]

1. I, Shri/Shrimati/Kumari …………………. whose particulars are given in the statement below,

………………………………….

………………………………….

………………………………….

………………………………….

[Name in full here]

hereby nominate the person(s) mentioned below to receive all the unpaid dues as per Code on

Wages, 2019 payable after my death 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

unpaid wages and other amounts shall be paid in proportion indicated against the name(s) of the

nominee(s).

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

of clause (f) of sub-rule (1) of Rule 2 of the Uttar Pradesh Code on Wages Rules, 2026.

3. I hereby declare that I have no family.

4. (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.

(c) the income of my dependent parents including my father-in-law/mother-in-law (in case of

women employees) from all sources does not exceed such income as specified by State

Government for this purpose.

(d) my husband's father/mother/parents is/are not dependent on my husband.

5. Nomination made herein invalidates my previous nomination.

Nominee(s):

(1) Name in full with full address of nominee(s) ………………………………..

Relationship with the employee …………………………

Age of nominee……………………….

Proportion by which the unpaid amount will be shared ……………..

(2) …………………..

(3) ………………….

(4) ……………..

Statement:

1. Name of employee in full ………………

2. Gender …………………..

3. Religion …………………

4. Whether unmarried/married/widow/widower …………………..

5. Department/Branch/Section where employed …………………..

6. Post held with Ticket or Serial No., if any ………………………

7. Date of appointment ………………………

8. Permanent address: Village ……………… Thana ……………… Sub-division

………………. Post Office ………………

District ………………. State…………………

Place:

Date:

Signature/Thumb impression

of the employee

Declaration by witnesses

Nomination signed/thumb impressed before me.

Name in full and full address of witnesses. Signature of witnesses

1.

2.

Place:

Date:

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: ………………

Date and Signature of the employer/

Officer authorised

Designation

Name and address of the

establishment or rubber stamp

thereof.

Acknowledgement by the employee

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

Date and Signature of the employee