FORM ‘I’
(See sub-rule (1) of rule 7)
APPLICATION
GRATUITY BY AN EMPLOYEE
TO’
…………………………………………………………………………………………………………………………………….. (Give here 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 on account of my superannuation/ retirement/
resignation after completion of not less than five years of continuous service/
total disablement due to accident/ total disablement due to disease with effect
from the…………………………………....... Necessary particulars relating to my appointment
in the establishment are given in the statement below.
STATEMENT
1. Name in full -
2. Address in full -
3. Department/ Branch/ Section where
last employed -
4. Post held with Ticket No. or Serial
No. in any -
5. Date of appointment -
6. Date and cause of termination of
service-
7. Total period of service-
8. Amount of wages last drawn-
9. Amount of gratuity claimed-
2. I was rendered totally disabled as a result
of-
(Here give the detail of the nature of disease
or accident)
Page-2
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FORMS] PAYMENT OF GRATUITY (CENTRAL) RULES, 1972
The evidences/ witnesses in support of my
total disablement are as follows :-
……………………………………………………………………………………………………………………
(Here give details)
3. Payment may please be made in cash/ open or
crossed bank cheque.
4.
As the amount of gratuity 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 employee
Place : ……………………………
Date : …………………………….
Notes :- 1. Strike out the words not
applicable
2. Strike out paragraph or paragraphs not applicable.
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