FORM [ee sub-rule (1) of Rule 6] NOMINATION. To (Give here name or description ofthe establishment wit full adress) 4. Shri/Shiemar Kuma on _-(Name in full here) whose particulars ae gven 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 criti the event of my death before that amount thas become payable, or having become payable has not been paid and diect that the sai amount of gratuity shal be paid in proportion indicated ‘against the name(s) ofthe nominee(s) 2. thereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause (h) of Section 2 of the Payment of Gratuity ‘et, 1972 3. hereby declare that have no family within the meaning of clause (h) of Section 2 ofthe said Act. 4. (0) My fether/mother/parents is/are not dependent on me. {(b) My husbane!s father/mother/parents is/are not dependent on my husband, 5. have excluded my husband from my family bya notice dated the tothe controling authority in terms ofthe proviso to clause (h) of Section 2 ofthe said Act. 6. Nomination made herein invalidates my previous nomination. NOMINEE (S) waite raperion By wR re name ful with ul ares of mminee|_Relatonhip wth the employee _iqauty wipe shaved h = for MAKSINGH FATHER. 6& ay: bp |tannoear | moTHER a7 soy: b el fe soon, statement }. Name of employee in full..mm- IDEVENDEA cHovet yA 2. Sex. CALE 3. Religion, WINOU wheter umarie/naiedwiow dower UNCAARRIED 5 beparmen/ranctVSecton where employed eros with chet No er Sera No, any. 7. Date of appointment trloy [eocs~ a Permanent adress: [vitage: @APDIANFnana: CH) AND. sub-division: CH UTA DWIA RA Post oficescx AN oistrt: CHMENDWARA|ste: C7) P- race: CHHTAY DW ARA won ofthe = Employee date: Poy [2025- Declaration by Witnesses Nomination signed/thumb impressed before me. achat | astra atom h VINAY OUREY hh Niey RAPASH PANDEY | Aste Place: CHT MDW ARA owe: (lot feo 2.57 Certificate by the Employer Certified thatthe particulars ofthe above nomination have been verified and recorded in this establishment. Employer's Reference No, if ny Signature ofthe employer/Officer authorised Designation Date: Name and address ofthe establishment or rubber stamp thereof. ‘ACKNOWLEDGEMENT BY THE EMPLOYEE Received the duplicate copy of nomination in Form "F” fled by me and duly certified by the employer. oatef 7 lot 2 257 Signature ofthe Employee ‘Wote— Sire out the words/paragraphs not applicable.