Form03 Payment of Gratuity Act 1972

FORM I
[See sub-rule (1) of rule 7]
To,
The Secretary,
ITI Education Committee,
Vidya Mandir, ITI Colony,
Dooravaninagar,
Bangalore-560016
Sir,
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 in 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. Not Applicable.
3. Payment may please be made in cash/draft.
Yours faithfully,
Place
Date.
Signature/Thumb-
impression of the applicant
employee.
FORM N
[See sub-rule (1) of rule 10]
Before the Controlling Authority under the Payment of Gratuity Act, 1972
Application No. Date..
Between
(name in full of the application with full address)
And
(name in full of the employer concerned with full address)
The applicant is an employee of the above-mentioned employer/nominee/legal heir of

late ___________________________, an 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 employees superannuation/
retirement/resignation on .. after completion of years
of continuous service/ his own aforesaid employees 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 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 . 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.

(here 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 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-
Date..
ANNEXURE
1. Name in full of applicant with address.
2. Basis of claim (death/superannuation/retirement/resignation/disability 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 eath 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.
18. Amount of gratuity claimed by the applicant.
Place
Date..
Signature/Thumb-
(note: Strike out the words not applicable)

Form03 Payment of Gratuity Act 1972

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FORM I

[See sub-rule (1) of rule 7]

3. Payment may please be made in cash/draft.

Application No. Date..

The applicant is an employee of the above-mentioned employer/nominee/legal heir of

2. The applicant submitted an application under rule . of the Payment of

3. The applicant submits that there is a dispute on the matter.

2. Basis of claim (death/superannuation/retirement/resignation/disability of employee).

3. Name and address in full of the employee.

4. Marital status of the employee (unmarried/married/widow/widower).

6. Department/Branch/section (where the employee was last employed) (if known).

8. Date of appointment of the employee (if known).

9. Date and cause of termination of service of 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 eath 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.

18. Amount of gratuity claimed by the applicant.

(note: Strike out the words not applicable)

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