[See rule 53(1)]
Nomination for Death-cum-Retirement Gratuity when the Govt. servant has family
and wishes nominate one member for more than on member thereof.
I hereby nominate the person/persons mentioned below who is /
are member (s) of my family and confer on him/them the right to receive to the
extent specified below, any gratuity that may be sanctioned by the Central Govt.
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 havingbecome admissible to me
on retirement may remain un-paid at my death,
Name and address of the nominees
/nominee.
Relationship with the government
Servant
Age
Amount of Share of gratuity
payable to each *
Name
and address, relationship and age of the person /or persons, if any to
whom the nominee shall pass in the event of nominee predeceasing the
Govt. servant but before Receiving payment of gratuity.
Amount share of gratuity
payable to
each**
* This column should be filled in so as to cover the whole amount of
gratuity.
** The amount share of gratuity shown in this column should cover the whole
amount /share payable to the original nominee.
This nomination supersedees the nomination made by me earlier on
which stands cancelled.
Note 1. The government servant should draw lines across the blank space below
the last entries to prevent the insertion of any name after he has signed.
2. Strike out which is not applicable.
Dated this day of at
Witnesses to sign here:-
1.
2.
3.
Signature of applicant
(TO BE FILLED IN BY THE HEAD OF OFFICE/ ACCOUNTS OFFICER)
Nomination by :
Designation :
Office :
Siganture of Head of Office / Accounts Officer.
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