| Sl.No. | Name of members of "Family" | Date of Birth | Relationship with official | Initial of Head of Office | Remarks |
|---|---|---|---|---|---|
I hereby undertake to keep the above particulars up to date by notifying to the Accounts Officer/Head of Office any addition or alteration.
* Family for this purpose means:-
(a) Wife, in the case of male government servant.
(b) Husband, in the case of a female government servant.
(c) Son's below 25 years of age and unmarried daughters below 25 years of age;
Including such son or daughter adopted legally before retirement.
NOTE: Wife and husband shall include respectively judicially separated wife and husband.
When the Government servant has a family and wishes to nominate one member or more than one member thereof.
I hereby nominate the person/persons mentioned below who is/are members(s) of my family, and confer on him/them the right to receive, to the extent specified below, any gratuity that may be sanctioned by the Central Government in the event of my death to the extent specified below, any gratuity which having become admissible terms on retirement may remain unpaid at my death:-
| Original nominee(s) | Alternate nominee(s) | ||||
|---|---|---|---|---|---|
| Name & address of nominee/nominees | Relationship with Govt. Servant | Age | Amount or share gratuity payable each* | Name, address, relationship & age of person to whom right conferred shall pass if nominee predeceases Govt. Servant | Amount or share of gratuity payable to each** |
* This column should be filled in so to cover the whole amount of the gratuity.
** The amount share of gratuity shown in this column should cover whole share payable to original nominee(s)
This nomination supersedes the nomination made by me earlier on which stands cancelled.
Dated this day of 20 at
Witness to Signature:
1.
2.
Signature of Government Servant
(To be filled by the Head of Office / Audit Officer)
Signature of Head of Office / Audit Officer:
Nomination by:
Designation:
Office:
Dated:
Designation:
I hereby nominate the persons who are members of my family to receive in the order shown below the family pension which may be granted by Government in the event of my death after completion of qualifying service:-
| Name & Address of nominee | Relationship with official | Age | Whether married or unmarried |
|---|---|---|---|
This nomination supersedes the nomination made by me earlier on which stands cancelled.
Dated this day of 20
Witness of Signature:
1.
2.
Signature of Government Servant
(To be filled in by Head of Office in case of Non-Gazetted Officer)
Nomination by:
Designation:
Office:
Date:
Signature of Head Of Office
(Acknowledging the receipt of Nomination Form by Head of Office)
To,
Shri/Smt.
In acknowledging the receipt of your nomination dated / Cancellation dated of nomination made earlier, in respect of gratuity/pension, I am to state that it has been duly placed on record.
Place:
Dated:
Signature of Head of Office
Designation: