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1. The document is a gratuity nomination form submitted by Thetchinamoorthi Kannaiyan, a married male Hindu employee of Larsen & Toubro Limited, to nominate his spouse Pradeepha Thetchinamoorthi to receive his gratuity payment of 100% in the event of his death. 2. Thetchinamoorthi declares that Pradeepha is a member of his family as defined in the Payment of Gratuity Act 1972. 3. The form provides Thetchinamoorthi's personal details like name, gender, religion, marital status, department, date of appointment, and permanent address in Chennai.

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Thetchina Moorthi
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69 views2 pages

View Form PDF

1. The document is a gratuity nomination form submitted by Thetchinamoorthi Kannaiyan, a married male Hindu employee of Larsen & Toubro Limited, to nominate his spouse Pradeepha Thetchinamoorthi to receive his gratuity payment of 100% in the event of his death. 2. Thetchinamoorthi declares that Pradeepha is a member of his family as defined in the Payment of Gratuity Act 1972. 3. The form provides Thetchinamoorthi's personal details like name, gender, religion, marital status, department, date of appointment, and permanent address in Chennai.

Uploaded by

Thetchina Moorthi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Psno : 20333747

GRATUITY NOMINATION FORM


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Request No. :24WF12053374 █ ▀▀▀ █ ▄▀ ▄▀▄██▀▄ █ ▀▀▀ █


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1. TO
LARSEN & TOUBRO LIMITED,
Shared Service Centre (SSC), L&T Campus, Powai, Mumbai – 400072.
(NAME & ADDRESS OF THE ESTABLISHMENT/COMPANY)
I, Shri/ Shrimati/ Kumari THETCHINAMOORTHI KANNAIYAN(Name in full, Surname first) whose particulars are given in the statement below
hereby nominate 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 and 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 that the person(s) mentioned is a / are member(s) of my family within the meaning of clause(h) of Section (2) of Payment of Gratuity Act 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of Section (2) of the said Act

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.
5. I have excluded my husband from my family by a notice dated the ____________ to the Trustee's/controlling authority in terms of the provision to clause (h) of
Section (2) of the said Act.
6. Nomination made herein invalidates my previous nomination

PAYSHEET NUMBER LOCATION REGION EMPLOYEE'S FATHER'S/HUSBAND'S NAME


20333747 CHENNAI CONSTRUCTION MURUGAIYAN KANNAIYAN

SLNO NAME & ADDRESS OF THE NOMINEE RELATIONSHIP WITH SHARE % AGE OF DATE OF BIRTH
OR NOMINEES (UPTO 3 Nos.) MEMBER * NOMINEE
1 PRADEEBHA THETCHINAMOORTHI . SPOUSE 100 35 25/05/1988
4/177 SHANTHI NIVAS BHARATHI CHELLAMAL STREET CHN
NANDANAM

* This column should be filled in so as to cover the whole of the amount that may stand to the credit of the member in the Fund which is payable in the event of his death.
Please refer definition of "Family" on Page 2.

-1- P.T.O
STATEMENT
NAME OF THE EMPLOYEE IN FULL SEX RELIGION WHETHER MARRIED/UNMARRIED /WIDOW/WIDOWER

THETCHINAMOORTHI KANNAIYAN Male HINDUISM Married


DEPARTMENT CADRE WITH PAYSHEET NUMBER DATE OF APPOINTMENT

LE21M992 CONTRACT EMPLOYEE (20333747) 22/06/2022

PERMANENT ADDRESS

4/177 SHANTHI NIVAS BHARATHI CHELLAMAL STREET

DECLARATION BY WITNESSES

Certified that the above nomination has been signed/thumb impressed before me.

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

Place______________________ Date___________________

CERTIFICATE BY THE EMPLOYER


Certified that the particulars of the above nomination have been verified and recorded in this establishment. Employee References No. if any:

Signature of the employer/authorised officer Designation Name & Address of the establishment or rubberstamp thereof Date

ACKNOWLEDGEMENT BY THE EMPLOYEE


Received the duplicate copy of nomination form filled by me and duly certfied by the employer

(Date)

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