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Nomination For Death-Cum-Retirement Gratuity

The document is a nomination form for death-cum-retirement gratuity. It allows the government employee to nominate individuals as beneficiaries to receive any gratuity payments in the event of the employee's death or unpaid gratuity after retirement. The form provides spaces to list original and alternate nominees along with their names, addresses, relationships, ages, and shares of the gratuity amount. It supersedes any prior nominations and requires signatures of the employee and witnessing officer.

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Rajula Gurva Reddy
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72 views

Nomination For Death-Cum-Retirement Gratuity

The document is a nomination form for death-cum-retirement gratuity. It allows the government employee to nominate individuals as beneficiaries to receive any gratuity payments in the event of the employee's death or unpaid gratuity after retirement. The form provides spaces to list original and alternate nominees along with their names, addresses, relationships, ages, and shares of the gratuity amount. It supersedes any prior nominations and requires signatures of the employee and witnessing officer.

Uploaded by

Rajula Gurva Reddy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NOMINATION FOR DEATH-CUM-RETIREMENT GRATUITY

I.herby,
nominate
the
person/persons
mentioned below who is/are members of family, and confer on his/them the right to receive, to
the extent specified below, any gratuity payment of which may be authorized by the Central
government in the event of my death while in service and the right to receive on my death, to the
extent specified below, any gratuity which having become admissible to me on retirement my
remain unpaid at death:
Original
Nominee(s)

Name & Address of Relationship with the Age


Amount or share of
nominee
Govt. Servant
gratuity payable to
each.*

1
2
3
4

Alternate Nominee(s)

5
6

Name, address, relationship and age of the person


Amount or share of
Or persons, if any, to which the right conferred on
gratuity payable to
The nominee shall pass in the event of the nominee
each***
Predeceasing the Govt. Servant or the nominee dying
After the death of the Govt. Servant by before
Receiving payment of gratuity.

*This column should be filled in so as to cover the whole amount of the gratuity.
***The amount/share of the gratuity shown in this column should cover the whole amount/share
payable to the original nominee.

-2This nomination supercedes the nomination


.which stands cancelled.

made

by

me

earlier

on

Note:- (a)
The Government Servant should draw lines across blank space below the last
entry to prevent the insertion of any name after he has signed.
(b)
Strike out which is not applicable.
Dated thisday of .2003at
Witness to Signature
1.
2.
Signature of Govt. Servant
Emp. Code..
Designation.
Email Address.
Tel .Intercom..
(To be filled by Head of Office)
Nomination by.
Designation...
Office.
Signature of Head of Office
Date
Designation
Acknowledgement receipt of this nomination
To,
.
.
.
Sir,
In acknowledging the receipt of your nomination, dated the. Cancellation,
dated the. Of the nomination made earlier in respect of gratuity in
form..I am to state that it has been duly placed on record.
Place:
Dated:
Signature of Head of Office
(Designatiion)
Note:- The Government Servant is advised that it would be in the interest of his nominees if
copies of the nominations and the related notices and acknowledgements are kept in safe custody
so that they may come into the possession of the beneficiaries in the event of his death.

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