FORM 'F'
[See sub-rule (1) of rule 6]
Nomination
POLYCAB INDIA LTD
To ……………………………………………………………………………………………………………..
[Give here name or description of the establishment with full address]
ANAND KUMAR
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)
Name in full with full Relationship with the Age of nominee Proportion by which
address of nominee(s) employee the gratuity will be
shared
KAJAL YADAV
1. SPOUSE 31 100%
2.
3.
so on.
Statement
1. Name of employee in full. ANAND KUMAR
2. Sex. Male
3. Religion. HINDU
4. Whether unmarried/married/widow/widower. MARRIED
5. Department/Branch/Section where employed. FMEG/RANCHI/
6. Post held with Ticket or Serial No., if any.
7. Date of appointment.
8. Permanent address. HOUSE NO. 102, SHIV NAGAR COLONY, NEAR
WAXPOL FACTORY, BUTTI MORE,
RANCHI-835217
TANGRATOLI SADAR BUTTI BUTTI
Village ……………… Thana ……………… Sub-division ………………. Post Office ………………
RANCHI JHARKHAND
District ………………. State…………………
Place RANCHI Signature/Thumb impression
Date 09-Sep-2024 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.
ANAND KUMAR
Date 09-Sep-2024 Signature of the employee
