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None - Gratuity Forms - Form N

This document is an application for direction from the Controlling Authority under the Payment of Gratuity Act of 1972. [1] The applicant is either an employee, nominee of a deceased employee, or legal heir of a deceased employee of the employer named. [2] The applicant previously submitted an application for gratuity to the employer, but the employer either offered a lower amount than due or rejected eligibility. [3] The applicant is now disputing the employer's decision and is requesting the Controlling Authority to determine the proper gratuity amount owed and direct the employer to pay it.

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Safe Star Souharda HO, Honavar
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191 views

None - Gratuity Forms - Form N

This document is an application for direction from the Controlling Authority under the Payment of Gratuity Act of 1972. [1] The applicant is either an employee, nominee of a deceased employee, or legal heir of a deceased employee of the employer named. [2] The applicant previously submitted an application for gratuity to the employer, but the employer either offered a lower amount than due or rejected eligibility. [3] The applicant is now disputing the employer's decision and is requesting the Controlling Authority to determine the proper gratuity amount owed and direct the employer to pay it.

Uploaded by

Safe Star Souharda HO, Honavar
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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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 employer concerned 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 employees superannuation on ……………./his own retirement/aforesaid
employee's resignation on ………………………….. after [date] completion of …………………. years of
continuous service/his own/aforesaid employee's total disablement with effect from ……. [date] due to
accident/disease/death of the aforesaid employee on ………………

2. The applicant submitted an application under rule ……………. of the Payment of Gratuity Act, 1972 on
the ………………… but the above-mentioned employer refused to entertain it/issued a notice dated the
under clause …………… of sub-rule of rule ………………… offering an amount of gratuity which is less than
me due/issued a notice dated the ………………………. under clause …………… of sub-rule …….. of rule
…………… rejecting my eligibility to payment of gratuity. The duplicate copy of the said notice is enclosed.

3. The applicant submits that there is a dispute on the matter. [Specify the dispute]

4. The applicant furnishes 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
Annexure

1. Name in full of applicant with full address.


2. Basis of claim:[Death/Superannuation/Retirement/Resignation/ 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 employer.
6. Department/Branch/Section where the employee was 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.
[Superannuation/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 Signature of the applicant/Thumb


Date impression of the applicant

Note: Strike out the words not applicable.

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