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ENCLOSURE 'D'
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NOMINATION FOR PAYMENT OF DEATH-CUM-RETIREMENT GRATUITY
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(To be furnished by the Employee)
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I hereby nominate the person(s) mentioned below, who is/are members of my family, and confer on them to receive, to the extent specified below, any gratuity
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that may be sanctioned by Government in the event of my death in service and the right to receive on my death, to the extent specified below, any grauity
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which having become admissible to me on retirement may remain unpaid at my death.
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Name & address of nominee(s)Relationship with the subscriber employeeAge Amount of Share of gratuity payable to each Contingencies on the happening of which the nomination shall become invalidName,address & relationship of the person(s), if any, to whom the right conferred on the nominee shall pass in the event of his/her predeceasing the employee or the nominee dying after the death of the employee but before receiving payment of the gratuity.Amount of share of gratuity payable to each
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SARJINA KHATUN
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* this nomination supersedes the nomination made by the erlier on....................................which stands cancelled.
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Dated this day of , 20..... at DIST- , PIN-
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Witnesses to Signature :
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1) Signature of Employee
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2)
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Note: (1) The employee shall draw lines across the blank, space below the last entry to prevent the insertion of any name after he has signed.
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 (2) Fourth column should be filled in so as to cover the whole amount of gratuity.
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 (3) The amount /share of gratuity shown in the last column to cover the whole amount/share payable to the original nominee.
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 Signature of Head of Office (Office Seal)
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