How to Fill Gratuity Form F

Payment of Gratuity (Central) Rules FORM 'F' See sub-rule (1) of Rule 6

Nomination

To, (Give here name or description of the establishment with full address)  The ABC AB C Company Co mpany Lt Ban!alore

I, ShriShrimati!umari ShriShrimati!umari Ch "areesh #umar  ("ame in full here) whose particulars are #iven in the statement below, hereb$ nominate the person(s) mentioned below to receive the #ratuit$ pa$able after m$ death as also the #ratuit$ standin# to m$ credit in the event of m$ death before that amount has become pa$able, or havin# become pa$able has not been paid and direct that the said amount of #ratuit$ shall be paid in proportion indicated a#ainst the name(s) of the nominee(s)% &% I hereb$ certif$ that the the person(s) person(s) mentioned mentioned isare isare a member(s) member(s) of m$ famil$ within within the meanin# meanin# of clause (h) of Section & of the 'a$ment of Gratuit$ ct, 1*&% +% I hereb$ hereb$ declare that I have have no famil$ famil$ within the the meanin# meanin# of clause clause (h) of Section & of the said ct% 

(a) $ father fathermot mother herpare parents nts isar isare e not not depende dependent nt on on me% me% (b) $ husband.s fathermotherparents isare not dependent on m$ husband%

/% I have e0cluded e0cluded m$ m$ husband husband from from m$ m$ famil$ famil$ b$ a notice notice dated dated the Not Re$uire the controllin# authorit$ in terms of the proviso to clause (h) of Section & of the said ct%

to

6% "ominati "omination on made made herein herein invalida invalidates tes m$ previou previous s nominatio nomination% n%

Nominee(s)

Name in full %ith full

Relationship %ith

A!e of 

Proportion &y %hih

aress of nominee(s)

the employee

nominee

the !ratuity %ill &e share

()

( )

(*)

(+)

1%

Ch ,imhahalam

Father

--

-./

&%

Ch 0ayala1shmi

Mother

-.

-./

+% So on%

,tatement 1% "ame of emplo$ee in full Chaaram "areesh #umar  &%

Se0 Male

+%

Reli#ion "inu

% hether unmarriedmarriedwidowwidower 2nmarrie /% 2epartment3ranchSection where emplo$ed "uman Resoure 3epartment 6% 'ost held with Tic4et "o% or Serial "o%, if an$ 4mployee 53 6 ..+ *% 2ate of appointment -7.*7.8 9:

'ermanent address5 Aress Of 4mployee ,houl Be Mentione "ere illa#e

Thana

Sub-division

'ost 7ffice

2istrict

State

'lace5 Ban!alore

4mployee ,i!nature Si#natureThumb-impression of the 8mplo$ee

2ate5 -7.*7.8

3elaration &y ;itnesses

"omination si#nedthumb-impressed before me "ame in full and full address of witnesses%

Si#nature of itnesses%

:

G 2ay Bhas1ar< Ban!alore< #arnata1a

:

,i!nature Of ;itness 

:

, ,unil #umar< "yera&a< Anhra Praesh

:

,i!nature Of ;itness 

'lace5 Ban!alore 2ate5 -7.*7.8

Certifiate &y the 4mployer 

9ertified that the particulars of the above nomination have been verified and recorded in this establishment% 8mplo$er.s Reference "o%, if an$ 4mployee 5 6 ..+ Si#nature of the emplo$er7fficer authorised 2esi#nation 4mployer ,i!nature 2ate5 -7.*7.8

"ame and address of the establishment or rubber stamp thereof%  Aress ,tamp Of 4sta&lishment

A1no%le!ement &y the 4mployee

Received the duplicate cop$ of nomination in :orm .:. filed b$ me and dul$ certified b$ the emplo$er% 4mployee ,i!nature 2ate5 -7.*7.8

Note:=Stri4e out the wordspara#raphs not applicable%

Si#nature of the 8mplo$ee