Nomination for Gratuity Death, when he has family

            When the Government servant has a family and wishes to nominate one member or more than one member, thereof.

I                                                                                                                       hereby, nominate the person/persons mentioned below who is/are members of family, and confer on his/them the right to receive, to the extent specified below, any gratuity payment of which may be authorized by the Central government in the event of my death while in service and the right to receive on my death, to the extent specified below, any gratuity which having become admissible to me on retirement my remain unpaid at death:-

Sl No.

Name & Address of Nominee(s)

Relationship with the    Govt. Servant

    Age

(Date of Birth)

Amount of share of gratuity payable to       each

Name, address, relationship and age of the person

Or persons, if any, to whom  the right conferred on The nominee shall pass in the event of the  nominee Predeceasing the Govt. Servant  or the nominee dying After the

death of           the Govt. Servant but  before

Receiving payment of gratuity.

Amount or share of gratuity payable to each

1

2

3

4

5

6

7

This nomination supersedes the nomination made by me earlier on                      which stands cancelled.

Note: - (a) The Government Servant should draw lines across blank space below the last

entry to prevent the insertion of any name after he has signed.

(b) Strike out which is not applicable.

1. This column should be filled in so as to cover the whole amount of the Gratuity.

     2.   The amount /share of the gratuity shown in this column should cover the whole amount /share payable to the original nominees

Dated this

day of

20

.at

Witness to Signature     

1.

2.

Signature of the Govt. Servant:

Emp. Code:

Designation:

Email Address:

Tel:

Intercom:

(To be filled by Head of Office)

Nomination by:

Designation:

Office:

Siognature of Head of Office:

Date:

Designation:

   Acknowledgement receipt of this nomination

To,  

Sir,

In acknowledging the receipt of your nomination, dated the              Cancellation, dated the               Of the nomination made earlier in respect of gratuity in form          I am to state that it has been duly placed on record.

Place:

Dated:

Signature of Head of Office:

Designation:

Note: - The Government Servant is advised that it would be in the interest of his nominees if copies of the nominations and the related notices and acknowledgements are kept in safe custody so that they may come into the possession of the beneficiaries in the event of his death.