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    Form F

    Uploaded by

    Jaganath Ravi
    1. Jaganath Ravi nominates his wife, Gopika Madhuvarshini, as the sole beneficiary to receive any gratuity payments after his death. 2. Jaganath declares that Gopika is a member of his family as defined by the Payment of Gratuity Act of 1972. 3. Gopika will receive 100% of any gratuity payments if Jaganath passes away before receiving the full amount or it is paid.

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    Form F

    Uploaded by

    Jaganath Ravi
    25 views3 pages
    1. Jaganath Ravi nominates his wife, Gopika Madhuvarshini, as the sole beneficiary to receive any gratuity payments after his death. 2. Jaganath declares that Gopika is a member of his family as defined by the Payment of Gratuity Act of 1972. 3. Gopika will receive 100% of any gratuity payments if Jaganath passes away before receiving the full amount or it is paid.

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    1. Jaganath Ravi nominates his wife, Gopika Madhuvarshini, as the sole beneficiary to receive any gratuity payments after his death. 2. Jaganath declares that Gopika is a member of his family as defined by the Payment of Gratuity Act of 1972. 3. Gopika will receive 100% of any gratuity payments if Jaganath passes away before receiving the full amount or it is paid.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    25 views3 pages

    Form F

    Uploaded by

    Jaganath Ravi
    1. Jaganath Ravi nominates his wife, Gopika Madhuvarshini, as the sole beneficiary to receive any gratuity payments after his death. 2. Jaganath declares that Gopika is a member of his family as defined by the Payment of Gratuity Act of 1972. 3. Gopika will receive 100% of any gratuity payments if Jaganath passes away before receiving the full amount or it is paid.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    FORM F

    [See sub-rule (1) of rule 6]


    NOMINATION
    To.
    ………………….
    (Give here name or description of the establishment with full address)
    1. Shri JAGANATH RAVI…………………
    (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 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 member(s) of my family


    within the meaning of Cl. (h) of Sec. 2 of the Payment of Gratuity Act, 1972.

    3. I hereby declare that I have no family within the meaning of Cl. (h) of Sec.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 proviso to Cl. (h) of Sec.2 of the said Act.

    6. Nomination made herein invalidates my previous nomination.

    NOMINEE(S)
    Name in full with Relationship with Age of nominee Proportion by
    full address of the employee which the gratuity
    nominee(s) will be shared
    1 2 3 4
    1.Gopika Wife 27 100%
    Madhuvarshini
    2.
    3.
    4
    and so on.

    STATEMENT
    1. Name of employee in full.
    Jaganath Ravi
    2. Sex. Male
    3. Religion. Hindu
    4. Whether unmarried/married/widow/widower. Married
    5. Department/Branch/Section where employed.
    Chennai
    6. Post held with Ticket or Serial. No., if any.
    7. Date of appointment.
    8. Permanent address. NO 16, A BLOCK, ANNAL APT, ANNAMALAI AVENUE,
    REDDIPALAYAM, CH-37

    Village……………..Thana…………….sub-division………………….
    Post office…………...District…Thiruvallur………………State……Tamil
    Nadu……………..

    Place………………
    Date………………. Signature/Thumb-impression
    of the employee.

    DECLARATION BY WITNESSES
    Fresh nomination signed/thumb-impressed before me.

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


    1……………….. 1…………………….
    2……………….. 2……………………..

    Place………………..
    Date………………..

    CERTIFICATE BY THE EMPLOYER

    Certificate that the particulars of the above nomination have been verified and
    recorded in this establishment.

    Employer’s Reference No., if any.


    Date……………..
    Signature of the employer/
    officer authorised.
    Designation.
    Name and address of the establishment
    Or rubber stamp thereof

    ACKNOWLEDGMENT 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 employer.


    Note,- strike out the words and paragraphs not applicable.

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