The employer shall display an abstract of the Act and the rules made thereunder in English and in the language under stood by the majority of the employees at a conspicuous place at or near the main entrance of the establishment.
To Form ``A" [See sub-rule (1) of Rule 3] Notice of Opening The Controlling Authority,
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 the Act.
6. Nature of lndustry.
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) Names & addresses of other Branches in India:-
1.
2.
3.
I verify that the information furnished above is true to the best of my knowledge and belief.
. Place.
Signature of the Employer with name and designation.
Date.
Form "8" [See sub-rule (2) of Rule 3] Notice of Change To The Controlling Authority, Name and address of the establishment.
Take notice that fo]]owing changes have taken place with effect from .................. in the particulars furnished by me in notice dated ............ in Form ``A".
Name.
Address.
Name of the Employer.
Nature of Business, Place.
Date.
To Signature of the Employer with name and designation.
Form "C,, [See sub-rule (3) of Rule 3] Notice of Closure The Controlling Authority, 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.
Form ``D" [See sub-rule (1) of Rule 5] Notice for excluding husband from family From:-
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. Permanentaddress.
Take notice that I, Shrimati ................... desire to exclude my husband from my family for the purposes of the Payment of Gratuity Signature/Thumb impression of the Employer.
Act,1972.
Place.
Date.
Declaration by witnesses The above notice was signed/thumb impressed before me.
Name in full and full address of witnesses.
1.
2.
Signature of witnesses.
Place.
Date TO, The Controlling Authority (through the employer) (Name and address of the employer here) For use by the Employer Received and recorded in this establishment.
Signature of the employer or an officer authorised in this behalf.
Reference No. by the employer.
Date To
1. (Employee).
2. The controlling Authority JVoce:- Strike out the words not applicable).
Form ``E,, [Sec sub-rule (2) of Rule 5] Notice of withdrawal of notice for excluding husband from family From:-
1. Name of the female employee.
2. Name or description of establishment where employed.
3. Postheldwith 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.
Date.
Signature/Thumb Impression of the Employer Declaration by witnesses The above notice was signed/thumb impressed before me.
Name in full and full address of witnesses. Signature of witnesses.
1.
2.
Place.
Date.
TO, Reference No.
The Controlling Authority (through the employer) (Name and address of the employer here).
For use by the Employer Received and recorded in this establishment.
Signature of the Employer or an Officer authorised in this behalf by the Employer.
Place.
Date.
To,
1. (Employee).
2. The controlling Authority (IVoCc:-Strike out the words not applicable).
Form ``F,, [See sub-rule (1) of Rule 6] Nomination To' (Give here name or description of the establishment with full address) I, Shri/Shrimati/Kumari ...... „ .... (Name in full here) whose particulars are given in the statement below, hereby nominate 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 the amount has become payable, of 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 person(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.
(b) 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 ....... „ ........ 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 address of nominee(s) 1 2 3 4 SO On.
Relationship with Age of the employee nominee Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed
6. PostheldwithTicket or serial No., if any
7. Date of appointment
8. Permanent address- Village.............
Post office„ ...............
Place.
Date.
Thana......
District."".......
Proportion by which the gratuity will be shared 4 Sub-divisional......
Signature/Thumb impression of the Employee.
Declaration by witnesses Nomination signed/thumb impressed before me Name in full and full address of witnesses.
1.
Signature of witnesses.
1.
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 Date......
Signature of the Employee/Officer authorised 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 IVoCc:-Strike out the words/paragraph not applicable.
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 below, have acquired a family within the meaning of clause(h) of Section 2 of the Payment of Gratuity Act, 1972 ......... „. with effect from the ............ (date here) .......... in the manner indicated below and therefore nominate afresh the persons 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, of having become payable has not been paid direct that the said amount of gratuity shall be paid in proportion indicated against the names of the nominees.
2. I hereby certify the persons nominated is/are member(s) of my family within the meaning of clause (h) of Section 2 of the said Act.
3. (a) My father/mother/parents is/are not dependent on me.
(b) My husband's father/mother 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.
NOMINEE(S) Name in full with full address of nominee(S) 1 1 2 3 4 SO 0n.
Relationship with Age of the employee nominee Proportion by which the gratuity wi]] be shared 4 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.
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. Postheldwith Ticket or serial No., if any.
7. Date of appointment.
8. Permanent address.
Village......................
Post office .................
Place.
Date.
Thana .................. „ Sub-division ......
District.....State Signature/Thumb impression of the Employee.
Declaration by witnesses Fresh nomination signed/thumb impressed before me.
Name in full and full address of witnesses. Signature of witnesses.
Date.
Certificate by the Employer Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No, if any Date...... Signature of the Employee/Officer authorised Designation.
Name and address of the Establishment or rubber stamp thereof.
Acknowledgement by the Employee Received the duplicate copy of nomination in Form...„ ........ filed by me on ............ duly certified by the employer.
Date ...... Signature of the Employer IVoce:-Strike out the words/paragraph not applicable.
Form `H, [Sce 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 ............ (Name in full here) whose particulars are given in the statement below, hereby give notice that the nomination filed by me on ......... „.(Date) and recorded under your reference No .......... dated .......... shall stand modified in the following manner:- (Here given details of the modifications intended) Statement
1. Name of employee in full.
2. Sex.
3. Religion.
4. Whether unmarried/married/widow/widower.
5. Department/Branch/Section where employed.
6. Postheldwith Ticket or serial No., if any.
7. Date of appointment.
8. Permanent address.
Place.„..".....
Date.".....
Signature /Thumb impression of the Employee.
Declaration by witnesses Modification of nomination 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 above modification have been recorded. Employer's Reference No., if any.
Date......." Signature of the Employee/ Officer authorised Designation Name and address of the Establishment or rubber stamp thereof.
Acknowledgement by the Employee Received the duplicate of the notice for modification in Form ``H" filed by me on .............. duly certified by the employer.
Signature of the Employee Date.."'."'."...
IVoce:-Strike out the words/paragraph not applicable.
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/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. Nameinfull.
2. Address in full.
3. Department/Branch/Section/ where last employed.
4. Postheld with Ticket No. orserial 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/witnesses in support of my total disablement are as follow:- (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 Signature/Thumb impression of the applicant employee Place......
Date......"..
IVoce:-1. Strike out the words not applicable
2. Strike out paragraph or paragraphs not applicable.
Form ``J,, [Sge sub-rule (2) of Rule 7] TO, (Give here the 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 as a nominee of late (Name of the employee) ........... who was an employee of your establishment and died on ............ The gratuity is payable on account of the aforesaid employee while in service/superannuation of the aforesaid employee on ........... „ .... retirement or resignation of the aforesaid employee on ............ after completion of ............ „„ year 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 ofapplicantnominee.
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 the employee.
14. Reference No. of recorded nomination, if available.
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.
3. 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 there from.
Yours faithfully Signature/Thumb impression of the applicant employee Place."...
Date........
IVote.1. Strike out the words not applicable
2. Strike out paragraph 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) 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 as a legal heir of late (Name of the employee) ....... „ .... who was an employee of your ............. establishment and died on the .......... without making any nomination. The gratuity is payable on account of the death of the aforesaid employee while in service/superannuation of the aforesaid employee on the ........ after completion of ......... year 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 applicantlegal heir.
2. Address in full ofapplicantlegal 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. Relation of both of the applicant and the employee.
7. Date of appointment and total period of service of the employee.
8. Department/Branch/Section where the employee worked last.
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 mention in the above statement are true and correct to the best of my knowledge and belief.
3. Payment may please be made in cash/open or crossed bank cheque.
4. As the amount payable is less than Rupees one thousand, I shall request you to arrange for payment of the sum to due me by Postal Money Order at the address mentioned above, after deduction postal money order commission there from.
Yours faithfully Signature/Thumb impression of the applicant legal heir Place......
Date......
IVote:-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.)
You are hereby informed as required under clause (i) of sub-rule (1) of Rule 8 of the Rajasthan Payment of gratuity Rules, 1973 that a sum of Rs ..... (Rupees ............. ) is payable to you as gratuity/ as your share of gratuity in terms of nomination made by on ..... „ ........... and ............ recorded in this ........... as a legal heir to.: ............. and 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 postal 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.
Place:
Signature of the employer/ Authorised Officer.
Name or description of establishment or rubber stamp thereof.
Copy to the Controlling Authority.
IVoce:- 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 (1) or Rule 8 of the Rajasthan Payment of Gratuity Rules, 1973 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) Signature of the employer/Authorised Officer.
Place:
Date:
Name and description of establishment or rubber stamp thereof.
Copy to the Controlling Authority.
IVote:- Strike out the words not applicable.
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 ........
Dated.......
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 if 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 employees resignation ............... (date) ......... on„.„ ......... after completion of ......
years of continuous .„„ ......... (date) .............. service/his own/aforesaid employee's total disablement with effect from due to accident/decease/death of the aforesaid (date) ............ employee on ................
2. The applicant submitted an application under rule ........... of the payment of Gratuity Act,1972 on then.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 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 application submits that there is a dispute on the matter (specify the dispute).
4. The applicant furnished 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.
Signature/Thumb impression of the applicant.
Date :
Annexure
1. Name in full ofapplicantwith full address.
2. Basisofclaim.
(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)
5. Name and address in full of the employer.
6. Department/Branch/Section where the employee 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 the 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 as a nominee/legal heir
18. Amount of gratuity claimed by the applicant.
Signature/Thumb impression of the Applicant.
Place...............
Date............
IVoce:- Strike out the words not applicable.
Form 1`0" [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 Shri ............................. 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 Rajasthan Payment of Gratuity Rules, 1973 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 the ........... day of 20 ............. 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 flnal 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/defence.
Take notice that in a default of your appearance on the day before mentioned i.e.
application will be submission/heard and determined in your absence.
Given under my hand and seal, this ............. day of ....... 20 ......
Controlling Authority.
IVoce:-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 20 ........... 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.„ ....... 20 ....
IVoCcs..-(1) The portion not applicable to be deleted.
(2) The summons shall be issue 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 not 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.
Form ``Q" [See sub-rule (1) of Rule 16] Particulars of application under Section
1. SerialNo.
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.
Date.
Signature of the Controlling Authority.
Form "R,, /See Rule 17) TO, (Name and address of employer) Whereas Shri/Smt./Kumari on ...... „.„... (address) ...........,.. „ ..,. an employee 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 the 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, 1 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. 20 .........
Controlling Authority Copy to:- (Applicant under rule) He is advised to contact the employer for collection payment.
IVoce - the portion not applicable to be deleted.
Form ``S,, [See sub-rule (5) of Rule 18] Notice for payment of Gratuity as determined by Appellate Authority To, (Name and address of employer) 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, hereby direct you 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 20 ......
Controlling Authority Copy to,-
1. The Applicant ......
He is advised to contact the employer for collecting payment.
2. The appellate Authority.
IVofe.- The portion not applicable to be deleted.
Acknowledgement by the employee.
Received the duplicate copy of nomination in Form "F" filed by me and duly certified by the employer.
Signature of the Employee Dated..........
IVoCc.-Strike out the words/paragraph not applicable;
Form "T,, (See Rule 19) Application for recovery of gratuity Before the Controlling Authority under the Payment of Gratuity Act,1972.
Dated.........
Application No ,........
Between (Name in full of the applicant with address) 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 of the 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 (State) Rules, 1972 for payment of a sum of Rs ......
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 him 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 ......... „..due to me as gratuity in terms of your direction.
Signature/Thumb impression of the Applicant.
Place:
Date: