FORM 'D'

[See sub-rule (I) of rule 5]



Notice for excluding husband from family



From ………………………………………………………………



1. Name of the female employee.

2. Name or description of establishment where employed.

3. Post held with Ticket or Serial No., if any.

4. Department/Branch/Section where employed.

5. Permanent address.



Take notice that I, Shrimati ……………… desire to exclude my husband Shri ………….from my family for the purposes of the Payment of Gratuity Act, 1972.



Place Signature/Thumb impression

Date of the employee.





Declaration by witnesses



The above notice was signed/thumb impressed before me.



Name in full and full Signature of witnesses.

address of witnesses.

1. 1.

2. 2.



Place

Date



To



The Controlling Authority



(Through the employer)



[Name and address of the employer here]



For use by the employer



Received and recorded in this establishment.



Date Signature of the employer or an

officer authorised in this behalf

by the employer

Reference No.



To



1……………………… (Employee)



2. The Controlling Authority.