FORM
'A'
[See sub-rule (1) of rule 3]
Notice
of Opening
1.
Name and address of the Establishment.
2.
Name and designation of the Employer.
3.
Number of persons employed.
4.
Maximum number of persons employed on
any day during the preceding twelve months with date.
5.
Number of employees covered by the Act.
6.
Nature of industry.
7.
Whether seasonal.
8.
Date of opening.
9.
Details of Head Office/Branches.
(a)
Name and address of the head office.
Number of employees.
(b)
Names and addresses of other branches
in India
1.
2.
3.
I verify that the information furnished
above is true to the best of my knowledge and belief.
Place Signature
of the employer
Date with
name and designation
To
The Controlling Authority
…………………………….
…………………………….
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Ins. by G.S.R. 2868, dated
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FORM
'B'
[See sub-rule (2) of rule 3]
Notice
of Change
Name and address of
the Establishment,
Take notice that following changes have taken place with effect from …………………….. in the particulars furnished
by me in notice dated ………………….. on Form
A '.
Name.
Address.
Name of the employer.
Nature of business
Place Signature
of the employer
Date with
name and designation
To
The
Controlling Authority
……………………………
……………………………
FORM
'C'
[See sub-rule (3) of rule 3]
Notice
of Closure
Take notice that it is intended to
close down the establishment with effect from ……………….. The other details are furnished below:
1.
Name and address of the establishment.
2.
Name and address of the Head Office, if
any.
3.
Name and designation of the employer.
4.
Number of persons in employment.
5.
Number of employees entitled to
Gratuity.
6.
Amount of Gratuity involved.
Place Signature
of the employer
Date
with name and designation
To
The Controlling Authority
……………………………
……………………………
FORM
'D'
[See sub-rule (I) of rule 5]
Notice
for excluding husband from family
From ………………………………………………………………
1.
Name of the female employee.
2.
Name or description of establishment
where employed.
3.
Post held with Ticket or Serial No., if
any.
4.
Department/Branch/Section where
employed.
5.
Permanent address.
Take notice that I, Shrimati ………………
desire to exclude my husband Shri ………….from
my family for the purposes of the Payment of Gratuity Act, 1972.
Place Signature/Thumb
impression
Date of
the employee.
Declaration by witnesses
The above notice was signed/thumb impressed before me.
Name in full and full Signature
of witnesses.
address of witnesses.
1. 1.
2.
2.
Place
Date
To
The Controlling Authority
(Through the
employer)
[Name and address of the employer here]
For use by the employer
Received
and recorded in this establishment.
Date
Signature
of the employer or an
officer
authorised in this behalf
by
the employer
Reference No.
To
1………………………
(Employee)
2. The Controlling Authority.
*FORM 'E'
[See sub-rule (2) of rule 5]
Notice of withdrawal of notice for excluding husband from family
1. Name
of the female employee.
2. Name
or description of establishment where employed.
3. Post
held with Ticket or Serial No., if any.
4. Department/Branch/Section
where employed.
5. Permanent
address.
Take notice
that I, Shrimati ……………. hereby
withdraw the notice dated whereby ………….
I exclude my husband Shri …………..
from my family for the purposes of the Payment of Gratuity Act, 1972. The
earlier notice was recorded under your reference No. …………….. dated …………
Place Signature/Thumb
impression
Date
of the employee.
Declaration by witnesses
The above notice of withdrawal was signed/thumb impressed
before me.
Name in full and full Signature
of witnesses.
address of witnesses.
1.
1.
2.
2.
Place
Date
To
The Controlling
Authority.
(Through the
employer)
[Name and address of
the employer]
For use by the employer
Received and
recorded in this establishment.
Reference No. Signature of the employer or
Date officer
authorised.
Seal or rubber stamp of the
establishment.
To
1. ………………… (Employee)
2. The
Controlling Authority.
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Forms D and E have become redundant as rule 5 of these
Rules have become redundant because of proviso to sub-clause (ii) of clause
(h) of section 2 of the Payment of Gratuity Act, 1872 has been omitted by the
Payment of Gratuity (Amendment) Act, 1987 (22 of 1987), sec. 2 (w.e.f.
1-10-1987), Ed.
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FORM 'F'
[See sub-rule (1) of rule 6]
Nomination
To ……………………………………………………………………………………………………………..
[Give here name
or description of the establishment with full address]
I.
Shri/Shrimati/Kumari …………………. 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)
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Name in full with
full address of nominee(s)
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Relationship with
the employee
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Age of nominee
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Proportion by which the gratuity will be
shared
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1.
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2.
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3.
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so on.
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Statement
1. Name
of employee in full.
2. Sex.
3. Religion.
4. Whether
unmarried/married/widow/widower.
5. Department/Branch/Section
where employed.
6. Post
held with Ticket or Serial No., if any.
7. Date
of appointment.
8. Permanent
address.
Village ……………… Thana
District ……………….
State…………………
Place Signature/Thumb
impression
Date 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.
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
Date Name
and address of the
establishment 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.
Date Signature
of the employee
FORM 'G'
[See sub-rule (3) of rule 6]
Fresh Nomination
To ………………………………………………………………………………………………………….
[Give here name or description of
the establishment with full Address]
I,
Shri/Shrimati ………………… [Name in full
here] whose particulars are given in the statement below, have acquired a
family within the meaning of clause (h) of section (2) of the Payment of
Gratuity Act, 1972 with effect from the ……………………
[date here] in the manner indicated below and therefor nominate afresh 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 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 the person(s) nominated is a/are member(s) of my family within the meaning
of clause (h) of section 2 of the said Act.
3.
(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.
4. 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.
Nominee(s)
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Name in full with
full address of nominee(s)
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Relationship with
the employee
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Age of nominee
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Proportion by which the gratuity will be shared
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1.
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2.
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3.
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4.
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so on.
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Manner of acquiring a "family"
[Here give
details as to how a family was acquired, i.e., whether by marriage or parents
being rendered dependant or through other process like adoption].
Statement
1. Name
of the employee in full.
2. Sex.
3. Religion.
4. Whether
unmarried/married/widow/widower.
5. Department/Branch/Section
where employed.
6. Post
held with Ticket No. or Serial No., if any.
7. Date
of appointment.
8. Permanent
address.
Village ……………. Thana
District ………………..
State ……………….
Place Signature/Thumb
impression
Date of
the employee.
Declaration by witnesses
Fresh nomination signed/thumb impressed before me.
Name in full and full Signature
of witnesses.
addresses of witnesses.
1. 1.
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
Date Name
and address of the
establishment or rubber
stamp thereof.
Acknowledgement by the employee
Received
the duplicate copy of the nomination in Form ………… filed by me on ………… duly
certified by the employer.
Date Signature
of the employer
FORM 'H'
[See sub-rule (4) of rule 6]
Modification or nomination
To ………………………………………………………………………………………………
[Give here name or description of
the establishment with full address]
I,
Shri/Shrimati/Kumari ………………… [Name
in full here] whose particulars are given in the statement below, hereby give
notice that the nomination filed by me on [date] and recorded under
your reference No……….
dated ……………… shall stand modified in
the following manner:
[Here give details
of the modifications intended]
Statement
1. Name
of the employee in full.
2. Sex.
3. Religion.
4. Whether
unmarried/married/widow/widower.
5. Department/Branch/Section
where employed.
6. Post
held with Ticket No. or Serial No., if any.
7. Date
of Appointment.
8. Address
in full.
Place Signature/Thumb
impression
Date of
the employee
Declaration by witnesses
Certified that the above modification have been recorded.
Employer’s reference
No., if any. Signature
of the employer/
Officer
authorised
Designation
Name and
address of the
Establishment
or rubber
Stamp thereof.
Acknowledgement by the employee
Received the
duplicate copy of the notice for modification in Form ‘H’ filed by me on …………
Duly certified by the employer.
Date Signature
of the employee
Note: Strike out
the worlds not applicable.
FORM ‘I’
[See sub-rule (1) of rule 7]
Application of gratuity by an employee
To ………………………………………………………………………………………………………….
[Give here name or description of
the establishment with full address]
Sir/Gentlemen,
I beg to apply
for payment of gratuity to which I am entitled under sub-section (1) of section
4 of the Payment of Gratuity Act, 1972 on account of my superannuation/retirement/resignation
after completion of not less than five years of continuous service/ total
disablement due to accident/ total disablement due to disease with effect from
the …………… Necessary particulars
relating to my appointment in the establishment are given in the statement
below:
Statement
1. Name
in full.
2. Address
in full
3. Department/Branch/Section
where last employed.
4. Post
held with Ticket No. or Serial No., if any.
5. Date
of appointment.
6. Date
cause of termination of service.
7. Total
period of service.
8. Amount
of wages last claimed.
9. Amount
of gratuity claimend.
I was rendered
totally disabled as a result of
[Here give Detail]
Payment may
please be made in cash/open or crossed bank Cheque.
As the amount of
gratuity payable is less than Rupees one thousand, I shall request you to
arrange for payment of the sum to me by Postal Money Order at the address
mentioned above after deducting postal money order commission therefrom.
Yours faithfully,
Place Signature/Thumb
impression of
Date the
applicant employee.
Note:
1. Strike
out words not applicable.
2. Strike
out paragraph or paragraph not applicable.
FORM 'J'
[See sub-rule (2) of rule 7]
Application for gratuity by a nominee
To ………………………………………………………………………………………………………
[Give here the name or
description of the establishment with full address]
Sir/Gentlemen,
I beg to apply
for payment of gratuity to which I am entitled under sub-section (1) of section
4 of the Payment of Gratuity Act, 1972 as a nominee of late……………… [name of the employee] who was an employee of your
establishment and died on the ………………….
The gratuity is payable on account of the death of the aforesaid employee while
in service/superannuation of the aforesaid employee on ………………… retirement of/resignation of the aforesaid employee on ……………….. after completion of ……………… years of service/total
disablement of the aforesaid employee due to accident or disease while in
service with effect from the ………………….
Necessary particulars relating to my claim given in the statement below:
Statement
1. Name
of applicant nominee.
2. Address
of full in applicant nominee.
3. Marital
status of the applicant nominee (unmarried/married/widow/widower)
4. Name
in full of the employee.
5. Marital
status of employee.
6. Relationship
of the nominee with employee.
7. Total
period of service of the employee.
8. Date
of appointment of the employee.
9. Date
and cause of termination of service of the employee.
10. Department/Branch/Section
where the employee last worked.
11. Post
last held by the employee with Ticket or Serial No., if any.
12. Total
wages last drawn by the employee.
13. Date
of death and evidence/witness as proof of death of the employee.
14. Reference
No. of recorded nomination, if available.
15. Total
gratuity payable to the employee.
16. Share
of gratuity claimed.
2. I declare that
the particulars mentioned in the above statement are true and correct to the
best of my knowledge and belief.
3. Payment
may please be made in cash/crossed or open bank cheque
4. As the amount payable is less than Rupees one thousand,
I shall request you to arrange for payment of the sum due to me by Postal Money
Order at the address mentioned above after
deducting Postal Money Order commission therefrom.
Yours faithfully,
Place Signature/Thumb
impression
Date of
applicant nominee.
Note:
1. Strike
out the words not applicable.
2. Strike
out the paragraph or paragraphs not applicable.
FORM 'K'
[See sub-rule (3) of rule 7]
Application for gratuity by a legal heir
To ……………………………………………………………………………………………………….
[Give here the name or
description of the establishment with full address]
Sir/Gentlemen,
I beg to apply
for payment of gratuity to which I am entitled under sub-section (1) of section
4 of the Payment of Gratuity Act, 1972 as a legal heir of late ……………….. [name of the employee]
who was an employee of your establishment and died on the…… without making any nomination.
The gratuity is payable on account of the death of the
aforesaid employee while in service/ superannuation of the aforesaid employee
on the …………………. retirement or
resignation of the
aforesaid employee on the …………… after completion of ………………..
years of service/total disablement of the aforesaid employee due to accident or
disease while in service with effect from the ………….. Necessary particulars relating to my claim are given in the
statement below:
Statement
1. Name
of applicant legal heir.
2. Address
in full of applicant legal heir.
3. Marital
status of the applicant legal heir (unmarried/married/widow/widower)
4. Name
in full of the employee.
5. Relationship
of the applicant with the employee.
6. Religion
of both the applicant and the employee.
7. Date
of appointment and total period of service of the employee.
8. Department/Branch/Section
where the employee worked last..
9. Post
last held by the employee with Ticket or Serial No., if any.
10. Total
wages last drawn by the employee.
11. Date
and cause of termination of service of the employee (death or otherwise).
12. Date
of death of the employee and evidence/witness in support thereof.
13. Total
gratuity payable to the employee.
14. Percentage
of the gratuity claimed.
15. Basis
of the claim and evidence/witness in support thereof.
2. I declare
that the particulars mentioned in the above statement are true and correct to
the best of my knowledge and belief.
3. Payment may
please be made in cash/open or crossed bank cheque.
4. As the amount
payable is less than Rupees one thousand, I shall request you to arrange for
payment of the sum due to me by Postal Money Order at the address mentioned
above, after deducting Postal Money Order commission therefrom.
Yours faithfully,
Place Signature/Thumb
impression
Date of
applicant legal hair.
Note: Strike out
the words not applicable.
FORM 'L'
[See clause (i) of sub-rule (1) of rule
8]
Notice for payment of gratuity
To ……………………………………………………………………………………………………….
[Name and address of the
applicant employee/nominee/1egal heir]
You are hereby
informed as required under clause (i) of sub-rule (1) of rule 8 of the Payment
of Gratuity (Central) Rules, 1972 that a sum of Rs. ………. (Rupees…………………) is
payable to you as gratuity/as your share of gratuity in terms of nomination
made by ………… on………… and ……………… recorded
in this ………………as a legal heir of …………….. an employee of this ……………... establishment.
2. Please call
at ………………… on ………………….[date] at ………………
for collecting your
[Here specify place]
payment in cash/open or crossed cheque.
3. Amount
payable shall be sent to you by Postal Money Order at the address given in your
application after deducting the Postal Money Order commission, as desired by
you.
Brief statement of calculation
1. Total
period of service of the employee concerned: ……………… year ……… months.
2. Wages
last drawn.
3. Proportion
of the admission gratuity payable in terms of nomination/as a legal heir.
4. Amount
payable.
Place Signature
of the employer/
Date Authorised
Officer
Name or
description of
establishment
of rubber
stamp thereof.
Copy to: the
Controlling Authority:
Note: Strike out
the words not applicable.
FORM 'M'
[See clause (ii) of sub-rule (1) of rule
8]
Notice rejecting claim for payment of
gratuity
To
[Name and
address of the applicant employee/nominee legal heir]
You are
hereby informed as required under clause (ii) of sub-rule (i) of rule 8 of the
Payment of Gratuity (Central) Rules, 1972 that your claim for payment of
gratuity as indicated on your application in Form ……… under the said rules is not admissible for the reasons stated
below:
Reasons
[Here specify the
reasons]
Place Signature
of the employer/
Date Authorised
Officer.
Name or description of
establishment or rubber
stamp thereof.
Copy to: The
Controlling Authority:
Note: Strike out
the words not applicable.
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] [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/Thumb
impression
Date of
the applicant.
Note: Strike out the words not applicable.
FORM 'O'
[See sub-rule (1) of rule 11]
Notice for appearance before the
controlling authority
From:
The
Controlling Authority under the Payment of Gratuity Act, 1972.
To
…………………………………………………………………………………………………………………
[Name and address of the
employee/applicant]
Whereas
Shri …………………, an employee under
you/a nominee(s) legal heir (s) of Shri …………………
an employee under the above-mentioned employer, has/have filed an application
under sub-rule (1) of rule 10 of the Payment of Gratuity
(Central) Rules, 1972 alleging that …………
[A copy of
the said application is enclosed]
Now,
therefore, you are hereby called upon to appear before me at ………………… [place] either personally or
through a person duly authorised in this behalf for the purpose of answering
all material questions relating to the application on the ………………. day of 19 ………………….at
………… o'clock in
the forenoon/afternoon in support of/to answer the allegation; and as the day
fixed for your appearance is appointed for final disposal of the application,
you must be prepared to produce on that day all the witnesses upon whose
evidence, and the documents upon which you intend to rely in support of your
allegation/defence.
Take notice
that in default of your appearance on the day before mentioned the application
will be dismissed/heard and determined in your absence.
Give under my
hand and seal, this ……………. day
of ………..
19 ……
Controlling Authority
Note: Strike out the words and
paragraphs not applicable.
FORM 'P'
[See rule 14]
Summons
Before the
Controlling Authority under the Payment of Gratuity Act, 1972.
To
……………………………………………………………………………………………………………
[Name and
address]
Whereas your
attendance is required to give evidence/you are required to produce the
documents mentioned in this list below, on behalf of in the case arising out of
the claim for gratuity by …………..
from ………… and referred to this
Authority by an application under section 7 of the Payment of Gratuity Act,
1972, you are hereby summoned to appear personally before this Authority on the
……………. day of 19 …………. at ……….. o'clock in the forenoon/afternoon and to bring with you (or
to send to this Authority) the said documents.
List of Documents
1.
2.
3. so on Controlling
Authority
Dated this …………..
day of ………….. 19 ……..
Notes.- 1. The
portion not applicable to be deleted.
2. The
summons shall be issued in duplicate. The duplicate is to be signed and
returned by the person served before the date fixed.
3. In
case summons is issued only for producing a document and not to give evidence,
it will be sufficient compliance to the summons if the documents are caused to
be produced before the controlling authority on the day and hour fixed for the
purpose.
FORM 'Q'
[See sub-rule (1) of rule 19]
Particulars of application under section 7
1. Serial
No.
2. Date
of the Application.
3. Name
and address of the applicant.
4. Name
and address of the employer.
5. Amount
of gratuity claimed.
6. Dates
of hearing.
7. Findings
with date.
8. Amount
awarded.
9. Cost,
if any, awarded.
10. Date
of notice issued for payment of gratuity.
11. Date
of appeal, if any.
12. Decision
of the appellate authority.
13. Date
of issue of Final Notice for payment of gratuity.
14. Date
of payment of Gratuity by Employer with mode of payment.
15. Date
of Receipt of application for recovery of Gratuity.
16. Date
of Issue of Recovery Certificate.
17. Date
of Recovery.
18. Other
remarks.
19. Signed.
20. Date
FORM 'R'
[See Rule 17]
Notice for payment of Gratuity
To ……………………………………………………… [Name and
address of employer]
Whereas
Shri/Smt/Kumari ……………………. of ……………….. (address) an [employee under
you/a nominee(s) legal heir(s) of late ………………..
and employee under you, filed an application under section 7 of the Payment of
Gratuity Act, 1972 before me;
And whereas
the application was heard in your presence on and after the hearing I have come
to the finding that the said Shri/Smt./ Kumari …………………… is entitled to a payment of Rs ……….. as gratuity under the Payment of Gratuity Act, 1972;
Now, therefore,
I hereby direct to pay the said sum of Rs …………………
to Shri/Smt./Kumari ……………………….within
thirty days of the receipt of this notice with an intimation thereof to me.
Given under my
hand and seal, this ………………. day of …………… 19 ……….
Controlling Authority
Copy to:
(Applicant)
He is advised to
contact the employer for collecting payment.
Note.- The portion not applicable to be
deleted,
FORM 'S'
[See sub-rule (5) of rule 18]
Notice for Payment of Gratuity as
determined by Appellate Authority
To
[Name and address of employer]
Whereas a notice was given to you on ………………… Form 'R' requiring you to make
a payment of Rs ………… to
Shri/Smt./Kumari ……………………. as
gratuity under the Payment of
Gratuity Act, 1972;
Whereas you/the
applicant went in appeal before the appellate authority, who has decided that
an amount of Rs ………… is due to be
paid to Shri/Smt./Kumari ………………….. as gratuity due under the
Payment of Gratuity Act, 1972;
Now, thereof, I
hereby direct you to pay the said sum of Rs …………… to Shri/Smt./Kumari ………………
within 30 days of the receipt of this with an intimation thereof to me.
Given under my
hand and seal, this …………… day of ………… 19 …..
Controlling Authority.
Copy to:
1. The
Applicant.
He is advised to contact the
employer for collecting payment
2. The
Appellate Authority.
Note.- The
Portion not applicable to be deleted.
FORM 'T'
[See rule 19]
Application for recovery of gratuity
Before the
Controlling Authority under the Payment of Gratuity Act, 1972.
Application No ……….. Date
……………..
Between ……………………………………
[Name in full of the applicant
with address]
And
[Name in full of the employer
with full address]
The applicant
is an employee of the above-mentioned employer/a nominee of late …………. an employee of the above
mentioned employer/a legal heir of late …………...,
an employee of the
above mentioned employer, and you were pleased to direct
the said employer in your notice dated the …………….
under rule …………….. of the Payment of
Gratuity (Central) Rules, 1972 for payment of a sum of Rs ……….. as gratuity payable under the Payment of Gratuity Act, 1972.
2. The
applicant submits that the said employer failed to pay the said amount of
gratuity to me as directed by you although I approached him for payment.
3. The applicant
therefore prays that a certificate may be issued under section ……………… of
the said Act for the recovery of the said sum of Rs …………………. due to me as gratuity in
terms
of your direction.
Place
Signature/Thumb impression
Date
of the applicant
