Gratuity Nomination Template
Uploaded by
neha ShuklaGratuity Nomination Template
Uploaded by
neha ShuklaEmployee No.
_______________
(Mandatory)
FORM 'F'
See sub-rule (1) of Rule 6
Nomination
To,
Infosys Limited,
No.44, Electronics city,
Hosur Road,
Bangalore- 560 100
I, Shri/Shrimati/Kumari < Name of the Employee >
(Name in full here)
whose particulars are given 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 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/are a 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)
Name in full with full Relationship with the Age of Proportion by which
address of nominee(s) employee nominee the gratuity will be
shared
(1) (2) (3) (4)
1. < Name & address of the Nominee’s > <Relationship> <Age> < % of Share >
2.
3.
< Total % of share should be 100% >
Statement
1. Name of employee in full < Employee Name >
2. Sex < Employee Gender >
3. Religion < Employee Religion >
4. Whether unmarried/married/widow/widower < Marital Status of Employee >
5. Department/Branch/Section where employed < Leave this Blank >
6. Post held with Ticket No. or Serial No., if any < Employee No & Designation>
7. Date of appointment < Date of Joining IL >
8. Permanent address: < Address of the Employee >
Village Thana Sub-division
Post Office District State
Place :< Mention Place> < Employee Signature >
Signature/Thumb-impression of the
Employee
Date: <Mention Date>
Declaration by Witnesses
Nomination signed/thumb-impressed before me
Name in full and full address of witnesses. Signature of Witnesses.
1. 1.
2. 2.
< Employee can take witness from their colleagues >
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: Infosys Limited,
No.44, Electronics city,
Hosur Road,
Bangalore- 560 100
Acknowledgement by the Employee
Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.
< Employee Signature >
Date: Signature of the Employee
Note.—Strike out the words/paragraphs not applicable.
