The Payment of Gratuity (Central) Rules, 1972
FORM 'F'
[See sub-rule (1) of rule 6]
NOMINATION
To,
Infinite Computer Solutions (India) Limited
1. Shri/Shrimati/Kumari________________________________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 noiminee(s) .
2. I hereby certify that the person(s) mentioned is a/ 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 sa id 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 full address of Relationship Age of Proportion by
nominee(s) with the nominee which the
Employee gratuity will be
shared
1.
2.
3.
4.
Give name or description of the establishment with full address
Payment of Gratuity (Central) Rules, 1972
Statement
1. Name of employee in full:
2. Sex:
3. Religion:
4.Whether unmarried / married/ widow/ widower:
5. Department/ Bran ch / Section where employed:
6. Post held with Ticket No. or Serial No. if any:
7. Date of appointment:
8. Permanent address:
Village Sub-Division
Post Office District State
Place:
Date :
Signature/Thumb impression of the employee
Declaration by witnesses:
Nomination signed/thumb impressed before me:
Name in full and full address of witnesses: Signature Of witnesses:
1. 1.
2. 2.
Place: Date:
Certificate by the Employer
Certificate that the particulars of above nomination has been verified and recorder in this establishment.
Employer reference nos., if any
Designation
Name and address of the establishment Signature of the employer/ official
Date: or rubber stamp thereof Authorized
Acknowledge by the Employee
Received the du plication copy of nomination in form 'F' filed by me and duly certified by the employer.
Date: Signature of the employee
