The Payment of Gratuity (Central) Rules, 1972
FORM 'D'
[See sub-rule (I) of rule 5]
Notice for Excluding Husband from Family
From .......................................
1. Name ofthe female employee.
2. Name or description of establishment where employed.
3. Post held with Ticket or Serial No., if any.
4. Department/Branch/Section where employed.
5. Permanent address.
Take notice that I, Shrimati .................... desire to exclude my husband Shri .................. from my family for the purposes of the Payment of Gratuity Act, 1972.
| Place................... | Signature/Thumb impression Date of the employee. |
| Date.................... |
Declaration by witnesses
The above notice was signed/thumb impressed before me.
| Name in full and full address of witnesses. |
Signature of witnesses. |
| 1. | 1. |
| 2. | 2. |
Place.....................
Date......................
To
The Controlling Authority
(Through the employer)
[Name and address ofthe employer here]
For use by the employer Received and recorded in this establishment.
Date......................
Signature of the employer or an
officer authorised in this behalf
by the employer
Reference No.
To
1 ........................... (Employee)
2. The Controlling Authority.
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