Notice to Employer

Payment of Gratuity Act,1972
FORM-N
[See Sub-rule (I) of rule 10]
APPLICATION FOR DIRECTION
BEFORE THE CONTROLLING AUTHORITY UNDER THE PAYMENT OF GRATUITY
ACT, 1972.
Application No. date
BETWEEN
(Name in full of the applicant with full address)
AND
(Name in full of the applicant with full address)

The applicant is an employee of the above-mentioned employer’s nominee of late
an employee of the above mentioned employer’s legal heir of late…………………….. and
employee of the above mentioned employer, and is entitled to payment of gratuity under
section 4 of the payment of Gratuity Act, 1972, on account of his own aforesaid
employee’s superannuation on ………………….. his own retirement/aforesaid employee’s
resignation on ……………………………..(date) after completion of ……………………..
years of continuous service /his own aforesaid employee’s total disablement with effect
from…………………………… due to accident/disease death of the aforesaid employee on
……………………………..(date)…………………..
2. The applicant submitted an application under rule………………….of the Payment of

Gratuity Act.1972 on the ………………….but the……………………abovementioned
employer refused to entertain it/issued a notice date the……………..under
clause…………………of sub-rule…………………..or rule
………………………….offering an amount of gratuity which is less than my due issued) a
notice dated the
…………………………under clause………………….of rule………………..rejecting my
eligibility to payment of gratuity. The duplicate cope of the said notice is enclosed.
3. The applicant submits that there is a dispute on the matter (specify the dispute)
4. The applicant furnished the necessary particulars in the annexure hereto and prays
that the Controlling Authority may be pleased to determine the amount of gratuity
payable to the petitioner and direct the above-mentioned employer to pay the same to
the petitioner.
5. The applicant declares that the particulars furnished in the annexure hereto are true
and correct to the best of his knowledge and belief.
Date……………. Signature of the

applicant/thumb impression
of the applicant.
1. Name in full of applicant with full address.
2. Basis of claim
(Death/superannuating/Retirement/Disablement of employee)
3. Name and address in full of the employee.
4. Marital status of the employee
(Unmarried/married/widow/widower)
5. Name and address in full of the employee
6. Department/Branch/Section where the employee was last employed (if known)
7. Post held by the employee with Ticket or Serial No. if any (if known).
8. Date of appointment of the employee (if known)
9. Date and cause of termination of service of the employee (Superannuating
retirement/resignation/disablement/death)
10. Total period of service by the employee.
11. Wages last drawn by the employee.
12. If the employee is dead, date and cause thereof.
13. Evidence/witness in support of death of the employee.
14. If a nominee, No. and date of recording of nomination with the employer.
15. Evidence /witness in support of being a legal heir, if a legal heir.
16. Total gratuity payable to the employee (if known).
17. Percentage of gratuity payable to the applicant as a nominee/legal heir.
18. Amount of gratuity claimed by the applicant.
Place:
Date: Signature/ thumb impression of the applicant.
FORM ‘O’
[See-Sub-rule ® of Rule 11]
NOTICE FOR APPEARANCE BEFORE THE CONTROLLING AUTHORITY.
From:- The Controlling Authority under the Payment of Gratuity Act, 1972.
To
(Name and address of the employee/applicant)
Whereas Shri……………………………………………an employee under you/a

nominee(s) legal heir(s) of Shri………………………………………. an employee under
the above-mentioned employer, has/have filed an application under sub-rule(1) of rule-10
of the A&N Islands Payment of Gratuity Rules, 1973 alleging that.
[A copy of the said application is enclosed]
Now therefore you are hereby called upon to appear before me at (Place) either personally
or through a person duly authorized in this behalf for the purpose of answering all material
question relating to the application on the ………………..day of
19………..at………..O’clock in the forenoon/afternoon in support of/to answer the
allegation: and as the day fixed for your appearance is appointed for final disposal of the
application, you must be prepared to produce on that day all the witnesses upon whose
evidence, and the documents upon which you intend to rely in support of your
allegation/defense.
Take notice that in default of your appearance on the day before mentioned the application
will be dismissed hearted and determined in your absence.
Given under my hand seal this…………………..day of ……………. …………….. 19………………
Controlling Authority
NOTE :- Strike out the words and paragraphs not applicable.

FORM- R.
(See rule 17)
NOTICE FOR PAYMENT OF GRATUITY .
To
(Name and address of employer)
Whereas Shri/Smt./Kumari………………………………………………of
……………………….
(address) ……………………………………………………………………an employee
under you/a nominee(s) legal heir(s) of late………………………an employee under you,
filed an application under section 7 of the payment of Gratuity Act, 1972 before me:
And whereas the application was heard in your presence on and after the hearing I
have come to the finding that the said Shri/ Smti./
Kumari……………………………………………………………
is entitled to a payment of Rs…………………………………………….as gratuity under
the payment
of Gratuity Act, 1972.
Now, therefore, I hereby direct to pay the said sum of Rs………………………………

to Shri/ Smt./ Kumari……………………………………………………………within thirty
days of the receipt of this notice with an intimation thereof to me.
Given under my hand and seal, this……………………… day of ………………… 19.
Copy to :- Controlling Authority.
(Applicant under rule………….)
He is advised to contact the employer for collecting payment.

RELEVANT RULES
RULE 10-Application to the controlling authority for direction- (1) If any employer-
(i) refuses to accept a nomination or to entertain an application sought to be
filed under rule 7,or
(ii) issues a notice under sub-rule 8 either specifying an amount of gratuity
which is considered by the applicant less than what is payable or rejecting
eligibility to payment of gratuity, or
(iii) having received an application under rule 7 fails to issue any notice as
required under 8 within the time specified therein,
The claimant employee ,nominee or legal heir, as the case may be may, within ninety days
of the occurrence of the cause for the application apply in form ‘N’ to the controlling
authority for issuing a direction under sub-section (4) of section 7 with as many extra
copies as are the opposite party.
Provided that the controlling authority any application under this sub-rule on
sufficient cause being shown by the applicant ,after the expiry of the specified period.
(2) Application under sub-rule (1) and other documents relevant to such an
application shall be presented in person to the controlling authority or shall be sent to him
by registered post acknowledgement due.
RULE 11-Procedure for dealing with application for direction- (1) On receipt of an
application under rule 10 the controlling authority shall by issuing a notice in Form ‘O’ call
upon the applicant as well as the employer to appear before him on a specified date , time
and place either by himself or through his authorized representative together with all
relevant documents and witnesses, if any.

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Payment of Gratuity Act,1972

(Name in full of the applicant with full address)

2. The applicant submitted an application under rule………………….of the Payment of

Date……………. Signature of the

[See-Sub-rule ® of Rule 11]

NOTICE FOR APPEARANCE BEFORE THE CONTROLLING AUTHORITY.

(Name and address of the employee/applicant)

Whereas Shri……………………………………………an employee under you/a

[A copy of the said application is enclosed]

Given under my hand seal this…………………..day of ……………. …………….. 19………………

NOTE :- Strike out the words and paragraphs not applicable.

(See rule 17)

NOTICE FOR PAYMENT OF GRATUITY .

Now, therefore, I hereby direct to pay the said sum of Rs………………………………

Given under my hand and seal, this……………………… day of ………………… 19.

Copy to :- Controlling Authority.

(Applicant under rule………….)

He is advised to contact the employer for collecting payment.

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