The employer shall display an abstract of the Act and the rules made there under in English and Hindi at a conspicuous place at or near the main entrance of the establishment.
FORM ‘A’ [See sub-rule (1) of Rule 3] Notice of Opening
1. Name and address of the establishment.
2. Name and designation of the Employer.
3. Number of persons employed.
4. Maximum number of persons employed on any day during the preceding twelve months with date.
5. Number of employees covered by this Act.
6. Nature of Industry.
7. Whether seasonal.
8. Date of opening.
9. Details of Head Office Branches.
(a) Name and address of the Head Office. Number of employees.
(b) Name and address of other branches in India.
1.
2.
3.
7 Payment of Gratuity (Bihar) Rules, 1972 I verify that the information furnished above is true to the best of my knowledge and belief.
Signature of the employer with name and designation Place Date To, The Controlling Authority FORM ‘B’ [ See sub-rule (2) of Rule 3] Notice of Change Name and address of the Establishment.
Take notice that following changes have taken place with effect from ……………. in the particulars furnished by me in notice dated ……………………. on Form ‘A’ Name Address Name of the Employer.
Nature of Business.
Place Date Signature of the employer with name and designation.
To, The Controlling Authority FORM ‘C’ [See sub-rule (3) of Rule 3.]
Notice of Closure Take notice that it is intended to close down the establishment with effect from ……………… The other details are furnished below :-
(1) Name and address of the establishment.
(2) Name and address of the head Office, if any.
(3) Name and designation of the employer.
(4) Number of persons in employment.
(5) Number of employees entitled to Gratuity.
(6) Amount of Gratuity involved.
Place Date Signature of the Employer with name and designation 8 Payment of Gratuity (Bihar) Rules, 1972 To, The Controlling Authority, FORM ‘D’ [See Sub-rule (1) rule 5.]
Notice for excluding husband from family From –
(1) Name of the female employee.
(2) Name of description of establishment where employed.
(3) Post held with ticket or serial no, if any.
(4) Department / Branch / Section where employed.
(5) Permanent address.
Take notice that I, Shrimati …. …. …. …. ….
desire to exclude my husband Shri …. …. …. …. ….
from my family for the purposes of the Payment of Gratuity Act, 1972.
Place Signature / thumb impression of the Date employee.
Declaration by witnesses.
The above notice was signed / thumb impressed before me.
Name in full and full address of witness. Signature of witnesses
(1) (1)
(2) (2) Place Date To, The Controlling Authority (through the employer) (Name and address of the employer here.)
For use by the employer.
Received and record in this establishment.
Reference no. Signature of the employer or an officer authorized in this behalf by the employer.
Date To,
(1) (Employee).
(2) The Controlling Authority.
Note. - Strike out the words not applicable.
9 Payment of Gratuity (Bihar) Rules, 1972 FORM ‘E’ [See sub-rule (2) of rule 5] Notice of withdrawal of notice for excluding husband from family.
(1) Name of the Female employee.
(2) Name or description of establishment where employed.
(3) Post held with ticket or serial no, if any.
(4) Department / Branch / Section where employed,
(5) Permanent address.
Take notice that I, Shrimati … … … hereby withdraw the notice, dated …. …. ….whereby I exclude my husband shri …. …. …. …. from my family for the purposes of the Payment of Gratuity Act, 1972. The earlier notice was recorded under your reference no …. …. …. ….dated Place Date Signature/Thumb impression of the employee.
Declaration by witnesses.
The above notice of withdrawal was signed / thumb impressed before me.
Name in full and full address of witnesses. Signature of witnesses
(1) (1)
(2) (2) Place Date To, The Controlling Authority (through the employer).
(Name and address of the employer).
For use by the employer.
Received and recorded in the establishment.
Reference no, Signature of the employer or officer authorized Date Seal or rubber stamp of the establishment.
To,
(1) (Employee).
(2) The Controlling authority.
Note – Strike out the words not applicable.
FORM ‘F’ To, (Give here name or description of the establishment with full address).
I, Shri / Shrimati / Kumari … … … … … whose particulars (name in full here) 10 Payment of Gratuity (Bihar) Rules, 1972 are given in the statement below, hereby nominate the persons (s) mentioned below to receive the gratuity after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable, has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the name (s) of the nominee (s).
2. I hereby certify that the persons (s) mentioned is / are member (s) of my family within the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of section (2) of the said Act.
4. (a) My father / mother / parents is / are not dependent on me.
(a) My husband’s father / mother / parents is / are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the ……………………to the controlling authority in terms of the proviso to clause (h) of section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Nominee (s) Name in full with full Relationship with the Age of Proportion by which the Address of nominee (s). employee. nominee. gratuity will be shared.
(1) (2) (3) (4)
(1)
(2)
(3)
(4) so on Statement.
(1) Name of employee in full.
(2) Sex.
(3) Religion.
(4) Whether unmarried / married /widow / widower.
(5) Department / Branch / section where employed.
(6) Post held with ticket or serial no., if any.
(7) Date of appointment.
(8) Permanent address.
Village. Thana. Subdivision.
Post Office. District. State.
Place Signature / thumb impression of the employee.
Date Declaration by witnesses.
Nomination signed / thumb impressed before me.
11 Payment of Gratuity (Bihar) Rules, 1972 Name in full and full address of witnesses. Signature of witnesses.
(1) (1)
(2) (2) Place Date Certificate by the employee.
Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer’s reference no., if any.
Signature of the employer/officer authorized Date Designation Name and address of the establishment or rubber stamp thereof.
Acknowledgement by the employee.
Received the duplicate copy of nomination in Form ‘F’ filed by me and duly certified by the employer.
Date Signature of the employee.
FORM ‘G’ [See Sub-rule (3) of rule 6.]
Fresh Nomination.
To, (Give here name or description of the establishment with full address).
I, Shri/Shrimati.……………………….., whose particulars are given in the statement (name in full here) below, have acquired a family within the meaning of clause (h) of section 2 of the Payment Gratuity Act, 1972…………………………. with effect from the (date here)………………………… in the manner indicated below and therefore nominate afresh the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the name(s).
2. I herby certify the person(s) mentioned is/are member(s) of my family within the meaning of clause (h) of section 2 of the Act.
3. (a) My father/mother/parents is/are not dependent on me.
(b) My husband’s father/mother/parents is/are not dependent on my husband.
4. I have excluded my husband from my family by a notice, dated the………………………. to the controlling authority in terms of the proviso to clause (h) of section 2 of the said Act.
Note. – Strike out the words / paragraph not applicable.
12 Payment of Gratuity (Bihar) Rules, 1972 Nominee (s) Name in full with address of nominee (s).
Relationship with the employee.
Age of nominee Proportion by which the gratuity will be shared.
(1) (2) (3) (4)
(1)
(2)
(3)
(4) so on Manner of acquiring a “family” (Here give details as to how a family was acquired, i.e., whether by marriage or parents being rendered dependent or through other process like adoption).
(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) Permanent address.
Village Thana Subdivision Post Office District State Place...................
Date....................
Signature/thumb impression of the employee Declaration by witnesses Fresh nominated 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 particulars of the above nomination have been verified and recorded in this establishment.
Employer’s reference on., if any.
Date..................... Signature of the employer/officer authorized.
Designation.
Name and address of the establishment or rubber stamp thereof.
13 Payment of Gratuity (Bihar) Rules, 1972 Acknowledgement by the employee.
Received the duplicate copy of the nomination in Form............................................ filed by me on........................ duly certified by the employer.
Note. – Strike out words and paragraphs not applicable.
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..........................................................., whose particulars are given in the statement below, hereby (name in full here) give notice that the nomination filled by me on and recorded under your reference no. dated shall (stand) modified in the following manner: - (Here give details of the modification 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.
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 words not applicable.
14 Payment of Gratuity (Bihar) Rules, 1972 FORM ‘I’ [See sub-rule (1) of Rule 7] Application for gratuity by an employee To, (Give here name or description of the establishment with full address) Sir/Gentleman, 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 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 and cause of termination of service.
7. Total period of service.
8. Amount of wages last drawn.
9. Amount of gratuity claimed.
2. I was rendered totally disabled as a result of (here give the details of the nature of disease or accident) The evidences/witness in support of my total disablement are as follows:
(Here give details)
3. Payment may please be made in cash/open or crossed bank cheque.
4. As the amount of gratuity payable is less than Rupees one thousand, I shall request you to arrange for payment of the sum due to me by Postal Money Order at the address mentioned above after deducting Postal Money Order commission there from.
Yours faithfully, Place Signature/thumb-impression of the Date applicant employee.
Note. – (1) Strike out the words not applicable.
(2) Strike out paragraphs not applicable.
FORM ‘J’ [See sub-rule (2) of Rule 7] Application for gratuity by a nominee To, (Give here the name, or description of the establishment with full address).
Sir/Gentleman, 15 Payment of Gratuity (Bihar) Rules, 1972 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, as nominee of late (Name of the employee) who was an employee of your establishment and died on the . The gratuity is payable on account of death of the aforesaid employee while in service/superannuation of the aforesaid employee on retirement or resignation of the aforesaid employee on after completion of................................ years of service/total disablement of the aforesaid employee due to accident or disease while in service with effect from the Necessary particulars relating to my claim are given in the statement below:
Statement
1. Name of the applicant nominee.
2. Address in full of the applicant nominee.
3. Marital status of the applicant nominee.
(unmarried/married/widow/widower).
4. Name in full of the employee
5. Marital status of employee.
6. Relationship of the nominee with the employee.
7. Total period of service of the employee.
8. Date of appointment of the employee.
9. Date and cause of termination of service of the employee.
10. Department/Branch/Section where the employee last worked.
11. Post last held by the employee with Ticket or serial no., if any.
12. Total wages last drawn by the employee.
13. Date of death and evidence/witness as proof of death of employee.
15. Total gratuity payable to the employee.
16. Share of gratuity claimed.
2. I declare that the particulars mentioned in the above statement are true and correct to the best of my knowledge and belief.
3. Payment may please be made in cash/crossed or open bank cheque.
4. As the amount payable is less than Rupees one thousand, I shall request you to arrange for payment of the sum due to me by Postal Money Order at the address mentioned above after deducting Postal Money Order commission therefrom.
Yours faithfully, Place Signature/thumb-impression of the Date applicant’s nominee.
Note. – (1) Strike out the words not applicable.
(2) Strike out paragraphs not applicable.
FORM ‘K’ [See sub-rule (3) of Rule 7] Application for gratuity by a legal heir To, (Give here the name or description of the establishment with full address).
16 Payment of Gratuity (Bihar) Rules, 1972 Sir/Gentleman, I beg to apply for payment of gratuity to which I am entitled under sub-section (1) of section 3 of the Payment of Gratuity Act, 1972, as a legal heir of late......................[Name of the employee] who was an employee of your establishment and died on the........................ without making any of your establishment and died on the................. without making any nomination. The gratuity is payable on account of the death of the aforesaid employee on the.................. retirement or registration of the aforesaid employee on the .................after completion of................................ years of service/total disablement of the aforesaid employee due to accident or disease while in service with effect from the....................................................
Necessary particulars relating to my claim are given in the Statement below:- Statement
1. Name of the applicant legal heir.
2. Address in full of the applicant legal heir.
3. Marital status of the applicant legal heir.
(unmarried/married/widow/widower).
4. Name in full of the employee.
5. Relationship of the applicant with the employee.
6. Religion of both the applicant and the employee.
7. Date of appointment and total period of service of the employee.
8. Department/Branch/Section where the employee last worked.
9. Post last held by the employee with Ticket or Serial No., if any.
10. Total wages last drawn by the employee.
11. Date and cause of termination of service of the employee (death or otherwise).
12. Date of death of the employee and evidence/witness in support thereof.
13. Total gratuity payable to the employee.
14. Percentage of the gratuity claimed.
15. Basis of the claim and evidence witness in support thereof.
2. I declare that the particulars mentioned in the above statement are true and correct to the best of my knowledge and belief.
3. Payment may please be made in cash/crossed or open bank cheque.
4. As the amount of gratuity payable is less than Rupees one thousand, I shall request you to arrange for payment of the sum due to me by Postal Money Order at the address mentioned above after deducting Postal Money Order commission therefrom.
Yours faithfully, Place- Signature/thumb impression of the Date- applicant legal heir.
Note. – Strike out the words not applicable.
FORM ‘L’ [See clause (i) of sub-rule(1) of Rule 8] Notice for payment of gratuity.
To, [Name and address of the applicant employee nominee legal heir] 17 Payment of Gratuity (Bihar) Rules, 1972 You are hereby informed as required under clause (i) of sub-rule (1) of rule 8 of the Payment of Gratuity (Bihar) Rules, 1972 that a sum of Rs......... (Rupees.........) is payable to you as gratuity in terms of nomination made by............. on..................... and..................... recorded in this................. as a legal heir of................. an employee of this................ establishment.
2. Please call at ... ... ... ... .... ... ... ... .... .... .... .... ..... ..... .... .... on ... .... .... .... .... .... ..... ..... .... ..... ....
[Here specify place] [Date] at ... ... .... .... .... ..... ..... ..... ..... .... .... for collecting your payment in cash/open or crossed cheque.
(time)
3. Amount payable shall be sent to you by Postal Money Order at the address given in your application after deducting the money order commission, as desired by you, by ... .... ..... ..... ..... ....
Brief statement of calculation
1. Total period of service of the employee concerned: - ... ... .... .... years .... .... .... .... ..... .... months.
2. Wages last drawn.
3. Proportion of the admissible gratuity payable in terms of nomination as a legal heir.
4. Amount payable.
Signature of employer/Authorised Officer.
Place- Date- Name or description of establishment or rubber stamp thereof.
Copy to the Controlling Authority.
Note. – Strike out the words not applicable.
FORM’M’ [See clause (ii) of sub-rule (1) of Rule 8] Notice rejecting claim for payment of gratuity To, (Name and address of the applicant employee/nominee legal heir).
You are hereby informed as required under clause(ii) of sub-rule(i) of rule 8 of the Payment of Gratuity (Bihar) Rules, 1972 that your claim for payment of gratuity as indicated on your application in Form.. ... .. ... ... ... .. under the said rules is not admissible for the reasons stated below: - Reasons (Here specify the reasons) Place - Signature of the employer/Authorized Officer.
Date- Name or description of establishment or rubber stamp thereof.
Copy to the Controlling Authority Note. – Strike out the words not applicable.
18 Payment of Gratuity (Bihar) Rules, 1972 FORM’N’ [See sub-rule (1) of Rule 10] Application for direction Before the Controlling Authority under the Payment of Gratuity Act, 1972.
Application No..................................... Date............................................
Between (Name in full of the applicant with full address).
and (Name in full of the employer concerned with full address) The applicant is an employee of the above-mentioned employer’s nominee 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 gratuity under section 4 of the Payment of Gratuity Act, 1972, on account of his own/aforesaid employee’s superannuation on ................................................................................................................
(date) his own retirement/aforesaid employee’s resignation on....................................................after (date) 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..............................
(date)
2. The application submitted an application under rule.............................................. of the Payment of Gratuity Act, 1972 on the....................................... but the above-mentioned employer refuse to entertain it/issued a notice dated the .......................... under clause ............................ of sub-rule of the.............................. offering an amount of gratuity which is less than my 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 this matter.
(Specify the dispute)
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 an direct the abovementioned 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 Signature of the applicant/Thumb impression of the applicant.
Annexure
1. Name in full of applicant with full address.
2. Basis of claim (Death/Superannuation/Retirement/Resignation/Disablement of employee).
3. Name and address in full of the employee.
4. Marital status of the employee (unmarried/married/widow/widower).
19 Payment of Gratuity (Bihar) Rules, 1972
5. Name and address in full of the employer.
6. Department/Branch/Section where the employer was last employed (if known).
7. Post held by the employee with Ticket or Serial No., if any (if known).
8. Date of appointment of employee (if known).
9. Date and cause of termination of service of the employee (superannuation) retirement/resignation/disablement/death).
10. Total period of service by the employee.
11. Wages last drawn by the employee.
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 the 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.
Place - Date - Signature/Thumb impression of the applicant.
Note. – Strike out the words not applicable.
FORM’O’ [See sub-rule (1)of rule 11] Notice for appearance before the controlling authority.
From:
The Controlling Authority under the Payment of Gratuity Act, 1972.
To..............................................................
(Name and address of the employer/applicant) Whereas................................................................................, an employee under you/a nominee(s) legal heir(s) of Shri.............................................................. an employee under the above-mentioned employer has/have filed an application under sub-rule (1) of rule 10 of the Payment of Gratuity (Bihar) Rules,1972 alleging that..................................................................................................................................................
[A copy of the said application is enclosed] Now, therefore, you are hereby called upon to appear before me at............................................
(Place) either personally or through a person duly authorised in this behalf for the purpose of answering all material questions relating to the application on 20 Payment of Gratuity (Bihar) Rules, 1972 the.............................. day of 19....................... at.......O’ clock in the forenoon/afternoon in support of/to answer the allegation; and as the day fixed for your appearance is appointed for final disposal of the application, you must be prepared to produce on that day all the witnesses upon whose evidence, and the documents upon which you intend to rely in support of your allegation/defense.
Take notice that in default of your appearance on the day before mentioned the application will be dismissed/heard and determined in your absence.
Give under my hand and seal, this................. day of...............19 Controlling Authority Note. – Strike out the words and paragraphs not applicable.
FORM’P’ [See Rule 14] Summons Before the Controlling Authority under the Payment of Gratuity Act, 1972.
To..................................................................................................................
(Name and address) Whereas your attendance is required to give evidence/you are required to produce the documents mentioned in the list below, on behalf of............................................................................. in the case arising out of the claim for gratuity by............................................................ from......................................... and referred to this Authority by an application under Section 7 of the Payment of Gratuity Act, 1972, you are hereby summoned to appear personally before this authority on the day of 19............................ at..............................at...............................o’ clock in the forenoon/afternoon and to bring with you (or to send to this Authority) the said documents.
List of Documents
1.
2.
3.
so on.
Controlling Authority Dated, this............................. day of.......................................... 19..............................................
Note. - 1. The portion not applicable to be deleted.
2. The summons shall be issued in duplicate. The duplicate is to be signed and returned by the person served before the date fixed.
3. In case the summons is issued only for producing a document and to give evidence, it will be sufficient compliance to the summons if the documents are caused to be produced before the controlling authority on the day and hour fixed for the purpose.
21 Payment of Gratuity (Bihar) Rules, 1972 FORM ‘Q’ [See sub-rule (1) of Rule16] Particulars of application under section
1. Serial No.
2. Date of the application
3. Name and address of the applicant
4. Name and address of the employer
5. Amount of gratuity claimed
6. Dates of hearing
7. Findings with date
8. Amount awarded
9. Cost, if any, awarded
10. Date of Notice issued for payment of gratuity
11. Date of appeal, if any
12. Decision of the appellate authority
13. Date of issue of Final Notice for payment of gratuity
14. Date of Payment of Gratuity by Employer with mode of payment
15. Date of Receipt of application for recovery of Gratuity
16. Date of issue of Recovery Certificate
17. Date of recovery
18. Other remarks
19. Signed
20. Date FORM’R’ [See rule17] Notice for payment of gratuity To - - - - - - - - - - - - - - (Name and address of employer) Whereas Shri/Smt./Kumari- - - - - - - - - - - of- - - - - - - - - - - - - - (address) an employer under you/a nominee(s) legal heir(s) of late..................... an employee under you, filed an application under section 7 of the Payment of Gratuity Act, 1972 before me:
And whereas application was heard in your presence on and after the hearing I have come to the finding that the said Shri/Smt./Kumari............................. is entitled to a payment of Rs............................ as gratuity under the Payment of Gratuity Act, 1972;
Now, therefore, I hereby direct to pay the said sum of Rs................................... to Shri/Smt./Kumari............................ within thirty days of the receipt of this notice with an intimation thereof to me.
Given under my hand and seal, this................................ day of ............19 ..............................
Controlling Authority Copy to:
(Applicant under rule......................................)
He is advised to contact the employer for collecting payment.
Note. – The portion not application to be deleted.
22 Payment of Gratuity (Bihar) Rules, 1972 FORM ‘S’ [See sub-rule (5) of rule 18] Notice for Payment of Gratuity as determined by Appellate Authority.
To, [Name and address of employee] Whereas a notice was given to you on....................................................from ‘R’ requiring you to make a payment of Rs...........................to Shri/Smt./Kumari............................ as gratuity under the Payment of Gratuity Act, 1972; Whereas you/ the applicant went in appeal before the appellate authority, who has decided that an amount of Rs......................... is due to be paid to Shri/Smt./Kumari................................ as gratuity due under the Payment of Gratuity Act, 1972;
Now, therefore, I hereby direct to pay the said sum of Rs.......................... to Shri/Smt/Kumari.........................
within 30 days of the receipt of this notice with an intimation thereof to me.
Given under my hand and seal, this........................................... day of........ 19............
Controlling Authority Copy to:
1. The Applicant.
He is advised to contact the employer for collecting payment.
2. The Appellate authority.
FORM ‘T’ [See rule 19] Application for recovery of Gratuity Before the Controlling Authority under the Payment of Gratuity Act, 1972 Application No. Date Between and (Name in full of the employer with full address) The applicant is an employee of the above-mentioned employer/a nominee of late............................ an employee above-mentioned employer/a legal heir of late...................................................................................... an employee of the above-mentioned employer, and you were pleased to direct the said employer in your notice dated the............................. under rule.............................. of the Payment of Gratuity (Bihar) Rules, 1972 for payment of a sum of Rs.............................. as gratuity payable under the Payment of Gratuity Act, 1972.
2. The applicant submits that the said employer failed to pay the said amount of gratuity to me as directed by you although I approached for payment.
3. The applicant, therefore, prays that a certificate may be issued under section................................. of the said Act for recovery of the said sum of Rs......................... due to me as gratuity in terms of your direction.
Signature/Thumb impression of the applicant Place- Date- Note. – The portion not applicable to be deleted.
Note. – Strike out the words not applicable.