FORM—A

NOMINATION FOR DEATH – CUM- RETIREMENT GRATUITY

(When the Officer has a family and wishes

to nominate one member there of)

                 I hereby nominate the person mentioned below, which is a member of my family, and confer on him the right to receive any gratuity that may be Sanctioned by Government in the event of my death while in service and the right to receive on my death any gratuity which having become admissible to me on retirement may remain unpaid at my death.

 

Name and address of nominee

Relationship with  Officer

age

Contingencies on the having which the nomination shall become invalid

Name, address and relationship of the person or Persons, if any, to whom the right conferred on nominee shall pass in the event of the nominee predeceasing the officer of the *nominee dying after the death of the officer but before receiving payment of the gratuity.

Amount or share of gratuity payable of each*

1

2

3

4

5

6

 

 

               This nomination supercedes the nomination made by me earlier on which stands cancelled;

 

Dated this                              day of                                              200

Witness to signature

1.

2.

 

                                                                                                                                                  Signature of officer

__________________________________________________________________________________________    

               

                To be filled in by the Head of office in the case of a non gazette officer

                Nomination by

 

Designation                           Date                                                       Signature of Head of office

Office                                     Designation

____________________________________________________________________________________________________

 

 * This column should be filled in so as the cover the whole amount   gratuity.