MOLE/SAMADHAN PORTAL
JUSTICE TO WORKMAN MADE SIMPLE, EASY & QUICK
Proform for Industrial Disputes Online
(Case will be rejected for any false information & Action under IPC will be taken)
FORM – N
[See sub-rule (1) of rule 10]
APPLICATION FOR DIRECTION
Before the Controlling Authority under the Payment of Gratuity Act, 1972
Between
AZMATHULLA KHAN R 194, Nhig B-4, 5th Phase, Yelahanka New Town 560064
And
Rama Krishna Reddy #54, Ananthapura Road, Yelahanka 560064
(Principle Employer : Jampana Construction Private Limited)
,,,
The applicant is an employee of the above-mentioned employer/nominee/legal heir of late an employee of the above-mentioned
employer's legal heir of late and employee of the above mentioned employer, and is entitled to payment of gratuity under section 4 of the
Payment of Gratuity Act, 1972, on account of his own/aforesaid employee’s superannuation on / his own retirement/aforesaid employee's
resignation on after completion of years of continuous service/ his own /aforesaid employee’s total disablement with effect from . Due to
accident/disease/death of the aforesaid employee on
2. The applicant submitted an application under rule of the Payment of Gratuity Act, 1972 on the but the above-mentioned employer
refused to entertain it/issued a notice dated the under clause of sub-rule of rule offering an amount of gratuity which is less than me
due/issued a notice dated the . Under clause of sub-rule of rule . Rejecting my eligibility to payment of gratuity. The duplicate copy of the
said notice is enclosed.
3. The applicant submits that there is a dispute on the matter.
4. The applicant furnishes the necessary particulars in the annexure hereto and prays that the controlling authority may be pleased to
determine the amount of gratuity payable to the petitioner and direct the above mentioned employer to pay the same to the petitioner.
5. The applicant declares that the particulars furnished in the Annexure hereto are true and correct to the best of his knowledge and
belief.
Date:12-05-2025 Signature/Thumb-impression of the applicant
Annexure
1. Name in full of applicant with address *
Azmathulla Khan R
2. Basis of claim *
Resignation
3. Name and address in full of the employee *
Nhig B- th Phase Yelahanka New Town Bengaluru Urban Karnataka -
4. Marital status of the employee
Married
5. Name and address in full of the employer *
Jampana Construction Private Limited Ananthapura Road Behind Ramanashree California Resorts Off Doddaballapura Road Yelahanka
Bangalore -
6. Department/Branch/section (where the employee was last employed) (if known)
TECHNICAL
7. Post held by the employee with ticket or serial no. if any (if known)
SENIOR ENGINEER
8. Date of appointment of the employee (if known)
06-01-2014
9. Date and cause of termination of service of the employee *
30-04-2023
Resignation
10. Total period of service by the employee *
9
11. Wages last drawn by the employee *
50300
12. If the employee is dead, date and cause thereof
13. Evidence/witness in support of death of the employee
14. If a nominee. No. and date of recording of nomination with employer
15. Evidence/witness in support of being a legal heir, if a legal heir
16. Total gratuity payable to the employee (if known)
17. Percentage of gratuity payable to the applicant as a nominee/legal heir *
100
18. Amount of gratuity claimed by the applicant *
1000000
