NOMINATION FOR GRATUITY
PAYMENT OF GRATUITY
(SEE SUB-RULE (I) OF RULE 6)
FORM F NOMINATION FORM
(See Sub-Rule (1) of Rule 7)
To, Dotpe Pvt Ltd, GF, Paras Twin Towers, Sector 53, Gurgaon
(Give name or description of the establishment with full address)
1. Shri/Smt/Kum ______________________________________________________________________________________
(Name in Full here)
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the payment
after my death as also the gratuity standing to my credit in the event of my death before the 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) nominated is a/are 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 no 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 provision to clause (h) of section 2 of the said Act
6. Nomination made herein invalidates my previous nomination
Nominee (s)
Name in full with full Relationship with Age of Proportion by which the
address of Nominee(s) the employee nominee gratuity will be shared
1.
2.
3.
4.
NOMINATION FOR GRATUITY (continued)
Statement
1. Name of employee (in full): ____________________________________________________________________________
2. Sex: ______________________________________________________________________________________________
3. Religion: ___________________________________________________________________________________________
4. Whether unmarried/married/widow/widower: ______________________________________________________________
5. Department/Branch/Section where employed: _____________________________________________________________
6. Post held with Employee ID: ___________________________________________________________________________
7. Date of appointment: ________________________________________________________________________________
8. Permanent Address: _________________________________________________________________________________
Village: _________________________ Thana: _________________________ Sub-division: ________________________
Post Office: _________________ District: ___________________ State: _____________ PIN Code: _________________
Place: __________________________ Signature/Thumb Impression of the Employee
Date: ___________________________
Declaration by Witness
Nomination signed/thumb impressed before me
Name in full and full address of witness Signature of witness
1 1
2 2
Place: __________________________________ Date: ________________________________
Certification by 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 authorized Designation
_________________________
Date: ____________________ Name and address of the establishment/Rubber Stamp thereof
Acknowledgement by the Employee
Received the duplicate copy of nomination in Form "F" filled by me duly certified by the employer
Date: _____________________ Signature of the employee
