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FORM4D

1. The document is a nomination form for designating recipients of an employee's death gratuity or unpaid retirement gratuity in the event of their death with no family. 2. It requests information such as the name, age, address, and relationship of the nominees, as well as the amount or share of the gratuity to be paid to each. 3. The employee must sign and date the form before witnesses, and it is then submitted to the Head of Office for acknowledgment and record keeping.

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115 views3 pages

FORM4D

1. The document is a nomination form for designating recipients of an employee's death gratuity or unpaid retirement gratuity in the event of their death with no family. 2. It requests information such as the name, age, address, and relationship of the nominees, as well as the amount or share of the gratuity to be paid to each. 3. The employee must sign and date the form before witnesses, and it is then submitted to the Head of Office for acknowledgment and record keeping.

Uploaded by

akhil ajmal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM 4D

[Referred to in Rule 76(a), Part III, K.S.R}


NOMINATION FOR D.C.R. GRATUITY

When the employee has no family

I, having no family, hereby nominate the persons mentioned below and


confer on them the right to receive to the extent specified below, 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, to the extent specified below
any gratuity which having become admissible to me on my retirement may
remain unpaid at my death.
Contingencies on the happening of which the nomina-

Name, address and relationship of the person or, per-


sons if any to whom the right conferred on the nomi-
nee shall pass in the event of the nominee predeceas-
ing the employee or the nominee dying after the death
of the employee but before receiving payment of the

Amount or share or gratuity payable to each


Amount or share or gratuity payable to each

Name and
Age
addresses of
Relationship with employee

nominees
tions shall become invalid

gratuity

1 2 3 4 5 6 7
This nomination supersedes the nomination made by me earlier on.
…………….which stands cancelled.

N.B.- The Officer should draw lines across blank space below the
last entry to prevent the insertion of any name after he had signed.

Date this ……………..day of ……….20……….at………….…………..

Witness to signature:

1…………………..

2…………………..
Signature of employee

(To be filled by the Head of Office in the case of non-gazetted employee)

Nomination by ………………..Signature of Head of the


Office………………

Designation……………………Date………………..

Office…………………………Designation…………
Pro forma for acknowledging the receipt of the nomination form by
the Head of Office/Audit Officer

To,
…………………………..
…………………………..
…………………………..
…………………………..
Sir,

In acknowledging the receipt of your nomination dated ……………/


cancellation dated…………../ ……………..of the nomination made
earlier in respect of Death-cum-Retirement Gratuity in
Form………………..I am to state that they have been duly placed
on record.

Signature of Head of Office/Audit Officer


Dated………………… (Designation)

Note 1.This column should be filled in so as to cover the whole amount of


gratuity. If only one person is nominated the words “full” or “hundred
percent “ shall be indicated in the column

Note 2.The amount /share of gratuity shown in this column should cover the
whole amount /share payable to the original nominees.

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