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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 mentioned below, who are members of my family, and confer on them the right to receive, to the extent specified below, any gratuity that may
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be sanctioned by 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
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to me on retirement may remain unpaid at my death:
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Name and Address
of
Nominees		Reletionship
with
Employee		AgeAmount of Share
of Gratuity
Payable to each		Contingencies on the
happening of which
the nomination shall
become invalid		Name, Address and relationship of the person or persons,
if any, to whom the right conferred on the nominee
shall pass in the event of the nominee pre-deceasing 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

Rs. P.
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1234567
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* This nomination supersedes the nomination made by me earlier on-
which stands cancelled.
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Dated this
day of 202__ at
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Witness to Signature
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……………………………………………………………………………..
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12Signature of the Employee
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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/she 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 last column to cover the whole amount / share payable to the original nominee.
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* Strike out, if not applicable.
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Sunday, March 29, 2026
………..…….……………………………………………………………
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DateOffice SealSignature of Head of Office
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