FORM 'F'
See sub-rule (1) of Rule 6
Nomination
To,
(Give here name or description of the establishment with full address)
I, Shri/Shrimati/Kumari Full Name as per Identity Card
(Name in full here)
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/are a member(s) of my family within the meaning of
clause (h) of Section 2 of the 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 controlling authority in terms of the provison to clause (h) of Section 2 of the said
Act.
6. Nomination made herein invalidates my previous nomination.
Points 3 to 6 is applicable only in case of no dependents
Nominee(s)
Name in full with full Relationship with Age of Proportion by which
address of nominee(s) the employee nominee the gratuity will be
shared
(1) (2) (3) (4)
1. Provide Full Name and addrss as per the Relation with you Age as per the Pecentage you
identity would like to nominate
identity document of the nominee document
2. You can give multiple nominees and same instructions to be followed as per the Line 1
3.
So
on.
Statement
1. Name of employee in full Full Name as per Identity document
2. Sex Gender of yourself
3. Religion Mention your Religion
4. Whether unmarried/married/widow/widower Provdie your Marital Status
5. Department/Branch/Section where employed Mention the department where you are working - can be found on your Revoluters profile or offer letter
6. Post held with Ticket No. or Serial No., if any
7. Date of appointment Start Date at Revolut
8. Permanent address: Mention your Residential address
Village Thana Sub-division
Post Office District State
Place: Location
Signature
Signature/Thumb-impression
of the
Employee
Date: Date of signing
Declaration by Witnesses
Nomination signed/thumb-impressed before me
Name in full and full address of witnesses. Signature of Witnesses.
Witness from your collegue, friend or neighbour
1. 1. Signature
Witness from your collegue, friend or neighbour Signature
2. 2.
Location
Place:
Date: Sign 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 nomination in Form 'F' filed by me and duly certified by the employer.
Date: Signature of the
Employee
Note.—Strike out the words/paragraphs not applicable.
