The Payment of Gratuity (Central) Rules, 1972
FORM 'I'
[See sub-rule(1) of rule 7]
Application of gratuity by an employee
To ...................................................
[Give here name or description of the establishment with full address]
Sir/Gentlemen,
I beg to apply for payment of gratuity to which I am entitled under sub-section (1) of section 4 of the Payment of Gratuity Act, 1972 on account of my superannuation/retirement/resignation after completion of not less than five years of continuous service/ total disablement due to accident/ total disablement due to disease with effect from the ................... Necessary particulars relating to my appointment in the establishment are given in the statement below:
Statement
1. Name in full.
2. Address in full
3. Department/Branch/Section where last employed.
4. Post held with Ticket No. or Serial No., if any.
5. Date of appointment.
6. Date cause of termination of service.
7. Total period of service.
8. Amount of wages last claimed.
9. Amount of gratuity claimend.
I was rendered totally disabled as a result of
[Here give the details of the nature of disease or accident]
The evidences/witnesses in support of my total disablement are as follow:
[Here give details]
Payment may please be made in cash/open or crossed bank Cheque.
As the amount of gratuity payable is less than Rupees one thousand, I shall request you to arrange for payment of the sum to me by Postal Money Order at the address mentioned above after deducting postal money order commission therefrom.
Yours faithfully,
Signature/Thumb impression of
the applicant employee.
Place
Date
Note:
1. Strike out words not applicable.
2. Strike out paragraph or paragraph not applicable.
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