FORM 'G'

[See sub-rule (3) of rule 6]



Fresh Nomination



To ………………………………………………………………………………………………………….

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



I, Shri/Shrimati ………………… [Name in full here] whose particulars are given in the statement below, have acquired a family within the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972 with effect from the …………………… [date here] in the manner indicated below and therefor nominate afresh the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid direct that the said amount of gratuity shall be paid in proportion indicated against the name(s)

of the nominee(s).



2. I hereby certify the person(s) nominated is a/are member(s) of my family within the meaning of clause (h) of section 2 of the said Act.



3.

(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.



4. I have excluded my husband from my family by a notice dated the ………………. to the controlling authority in terms of the proviso to clause (h) of section 2 of the said Act.



Nominee(s)



Name in full with full address of nominee(s) Relationship with the employee Age of nominee Proportion by which the gratuity will be shared

1.

2.

3.

4.

so on.



Manner of acquiring a "family"



[Here give details as to how a family was acquired, i.e., whether by marriage or parents being rendered dependant or through other process like adoption].



Statement

1. Name of the employee in full.

2. Sex.

3. Religion.

4. Whether unmarried/married/widow/widower.

5. Department/Branch/Section where employed.

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

7. Date of appointment.

8. Permanent address.





Village ……………. Thana …………….. Sub-division ………………… Post Office …………………



District ……………….. State ……………….



Place Signature/Thumb impression



Date of the employee.



Declaration by witnesses



Fresh nomination signed/thumb impressed before me.



Name in full and full Signature of witnesses.

addresses of witnesses.



1. 1.

2. 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.

Signature of the employer/

officer authorised

Designation



Date Name and address of the

establishment or rubber

stamp thereof.



Acknowledgement by the employee



Received the duplicate copy of the nomination in Form ………… filed by me on ………… duly certified by the employer.



Date Signature of the employer