FORM ‘J’
(See sub-rule (2) of rule 7)
APPLICATION
GRATUITY BY A NOMINEE
TO’
…………………………………………………………………………………………………………………………………….. (Give here the name or description of the
establishment with full address)
Sir/ Gentlemen’
I beg to apply for payment of
gratuity to which I am entitled under sub-section (1) of section 4 of the
payment of Gratuity Act, 1972 as a nominee of late …………………………………………(name of the
employee) who was an employee of your ………………………………establishment and died on the
………………………The gratuity is payable on account of the death of the aforesaid
employee while in service/ superannuation of the aforesaid employee
on……………………………/ retirement or/ resignation of the aforesaid employee on
…………………………………after completion of ……………..years of service/ total disablement of
the aforesaid employee due to accident or disease while in service with effect
from the…………..……….. Necessary particulars relating to my claim are given in
the statement below.
STATEMENT
1.
Name of applicant nominee -
2.
Address in full of the applicant nominee -
3.
Marital status of the applicant nominee -
(unmarried/ married/ widow/ widower)
4. Name in full of the employee -
5.
Marital status of employee -
6.
Relationship of the nominee with the employee -
7.
Total period of service of the employee -
8.
Date of appointment of the employee -
9.
Date and cause of termination of service of the employee -
10. Department/ Branch/ Section where the
employee last worked-
Page-2
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11. Post last held by the employee with Ticket or
Serial No., if any -
12.
Total wages last drawn by the employee -
13.
Date of death and evidence/ witness as proof of death of the
employee
14.
Reference No. of recorded nomination if available
15.
Total gratuity payable to the employee
16.
Share of gratuity claimed
2. I
declare that the particulars mentioned in the above statement are true and correct to the best of my knowledge and
belief.
3. Payment
may please be made in cash/ crossed or open bank cheque.
4.
As the amount payable is less than rupees one thousand, I shall request you to arrange for payment of the sum due to
me by postal money order at the address mentioned above after deducting postal
money order commission therefrom.
Youys
faithfully,
…………………………………
Signature/Thumb-impression
of
The
applicant nominee
Place : ……………………………
Date : …………………………….
Notes :- 1. Strike out
the words not applicable
2. Strike out paragraph or
paragraphs not applicable.
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