*FORM 'E'

[See sub-rule (2) of rule 5]



Notice of withdrawal of notice for excluding husband from family



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 ……………. hereby withdraw the notice dated whereby …………. I exclude my husband Shri ………….. from my family for the purposes of the Payment of Gratuity Act, 1972. The earlier notice was recorded under your reference No. …………….. dated …………



Place Signature/Thumb impression

Date of the employee.



Declaration by witnesses



The above notice of withdrawal 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]



For use by the employer



Received and recorded in this establishment.



Reference No. Signature of the employer or

Date officer authorised.

Seal or rubber stamp of the

establishment.

To

1. ………………… (Employee)



2. The Controlling Authority.