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Nominee (SS: See Sub-Rule (1) of Rule 61

This document contains an employee's nomination form for payment of gratuity. The employee, Sombathint Surya Teja, nominates his father, Somba Thenle Vijaya Kumar, to receive any gratuity payment owed in the event of the employee's death. The employee certifies that his father is a member of his family as defined by law. He also provides his personal details like name, gender, religion, marital status, date of appointment, and permanent address. The nomination is signed by the employee and two witnesses. The employer has verified and certified the particulars of the nomination.

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surya teja
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215 views2 pages

Nominee (SS: See Sub-Rule (1) of Rule 61

This document contains an employee's nomination form for payment of gratuity. The employee, Sombathint Surya Teja, nominates his father, Somba Thenle Vijaya Kumar, to receive any gratuity payment owed in the event of the employee's death. The employee certifies that his father is a member of his family as defined by law. He also provides his personal details like name, gender, religion, marital status, date of appointment, and permanent address. The nomination is signed by the employee and two witnesses. The employer has verified and certified the particulars of the nomination.

Uploaded by

surya teja
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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FORME

See sub-rule (1) of Rule 61


Nomination
To
(Give here name or description of the establishment with full address)
1.1 Shri/Shrimati/Kumari .SAMEATHINT.SURYA.TJA..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
the 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 a/are member(s) of my family within the meaning of clause
(h) of Section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within thee meaning of clause (h) of Section 2 of the said Act.
4. (a) My tather/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 clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
NOMINEEIS)
Name in full with full address of |Relationship with the lAge of Nominee Proportion by which the
Nominee(sS employee
2
gratuity will be shared_

SOMBA THENLE VJAYA FATHER


100/
KUMAR

Statement
1. Name of employee in full SOMBATHINT SURYA TEJA
2. Sex MALE
3. Religion HTNDU
4. Whether unmarried/married/widowwidower UNMARRTED
5. Department/ Branch/Section where employed EXECUTTVE
6. Post held with Ticker No. or Serial No. if any NA
7. Date of appointment 25/03/2021 BANK BACkSTRE
8. Permanent Address :7634-H-25, SuRYA NAGAR, SEL
Thana Sub-division RLY KODUR.
Village
Post Office District State

Place Chennai Swnana S


Signature/Thumb impresslon of the employee
Date:
4 0 4121
Declaratlon by wltnesses
Nomination signed/thumb-impressed before me.
Name in full and full address of witnesses. Signature of Witnesses
1)

2)

Place: Chennai
Date: 1t/bH*

Certificate by theemplover recorded in this establishment.


Certified that the particulars of the above nomination have been verified and

authorised
Employer's Reference No. if any. Signature of the employer/Officer
Designation
Date

establishment
Name and address of the
or rubber-stamp thereof

Acknowledgement by theemplovee
nomination in Form 'F" filed by me certified
and duly by the employer.
Received the duplicate copy of

SmotUi.S
Signature of employee
Date 14o4/21
Note: Strike out the words/paragraphs not applicable

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