The Payment of Gratuity (Central) Rules, 1972
FORM 'H'
[See sub-rule (4) of rule 6]
MODIFICATION OF NOMINATION
To ..................................................
[Give here name or description of the establishment with full address]
I, Shri/Shrimati/Kumari ...................... [Name in full here] whose particulars are given in the statement below, hereby give notice that the nomination filed by me on [date] and recorded under your reference No .......... dated .................. shall stand modified in the following manner:
[Here give details ofthe modifications intended]
Statement
1. Name of the employee in full.
2. Sex.
3. Religion.
4. Whether unmarried/married/widow/widower.
5. Department/Branch/Section where employed.
6. Post held with Ticket No. or Serial No., if any.
7. Date of Appointment.
8. Address in full.
| Place | Signature/Thumb impression of the employee |
| Date |
Declaration by witnesses
| Modification of nomination signed/thumb impressed before me. Name in full and full address of witnesses. | Signature of witnesses. |
| 1. | 1. |
| 2. | 2. |
| Place |
| Date |
Certificate by the employer
Certified that the above modifications have been recorded.
Employer's reference No., if any.
Signature of the employer/
Officer authorised
Designation
Name and address of the
Establishment or rubber
Stamp thereof.
Acknowledgement by the employee
Received the duplicate copy of the notice for modification in Form 'H' filed by me on ............ duly certified by the employer.
| Date................... | Signature of the employee |
Note: Strike out the worlds not applicable.
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