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Payment of Gratuity Act, 1972: Form 'F'

1) Bristi Saha has nominated her mother Bobby Saha to receive 100% of her gratuity payable in the event of her death. 2) Bristi is unmarried and her mother is her only family member as defined by the Payment of Gratuity Act, 1972. 3) The nomination form was signed by Bristi and witnessed before being certified by her employer ICRA Analytics Limited.

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180 views3 pages

Payment of Gratuity Act, 1972: Form 'F'

1) Bristi Saha has nominated her mother Bobby Saha to receive 100% of her gratuity payable in the event of her death. 2) Bristi is unmarried and her mother is her only family member as defined by the Payment of Gratuity Act, 1972. 3) The nomination form was signed by Bristi and witnessed before being certified by her employer ICRA Analytics Limited.

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© © All Rights Reserved
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FORM 'F'

PAYMENT OF GRATUITY ACT, 1972


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

Nomination

To ICRA ANALYTICS LIMITED (17TH & 18TH FLOOR,INFINITY BENCHMARK BUILDING PLOT
G1 ,BLOCK-EP&GP,SECTOR-V,SALTLAKE CITY KOLKATA-700091,WB)

[Give here name or description of the establishment with full address]

I. Shri/ Shrimati /Kumari BRISTI SAHA…………………. whose particulars are given in the statement
below, [Name in full here]
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 the meaning of clause (h) of section (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 clause (h) of section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Proportion by
Name in full with full address of nominee(s) Relationship with the Age of which the
employee Nominee gratuity will be
shared
1.BOBBY SAHA MOTHER 48 YRS

2.

3.
Statement

1. Name of employee in full.- BRISTI SAHA

2. Sex. :FEMALE

3. Religion. : HINDU

4. Whether unmarried/married/widow/widower.: UNMARRIED

5. Department/Branch/Section where employed.: KNOWLEDGE SERVICE

6. Post held with Ticket or Serial No., if any.

7. Date of appointment. :29-12-2021

8. Permanent address.: P-69 ,1ST FLOOR BLOCK- BANGUR AVENUE RELIANCE FRESH JESSORE
ROAD NORTH 24 PARGANAS KOLKATA-700055

Village ……………… Thana ……LAKE TOWN………… Sub-division ………………. Post Office …BANGUR
AVENUE……………

District …24 NORTH PARGANAS……………. State………WEST BENGAL…………

Place: KOLKATA BRISTI SAHA


Signature/Thumb impression
Date:07-02-2022 of the employee

Declaration by witnesses

Nomination signed/thumb impressed before me.

Name in full and full Signature of witnesses.


address of witnesses.

1. 1.

Place

Date

2. 2.

Place

Date
Certificate by the employer

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

Employer's Reference No., if any. Signature of the employer/ officer authorised

Designation

Name address of the establishment


Date……………….. or rubber stamp thereof

Acknowledgement by the employee

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

BRISTI SAHA

Date:07-02-2021 Signature of the employee

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