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    Form 'F'

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    prince
    Form

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    © All Rights Reserved
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    Form 'F'

    Uploaded by

    prince
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    Form 'F'

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    prince
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    [ NEW EIN:- ]

    FORM 'F'
    See sub-rule (1) of Rule 6

    Nomination
    To,

    Utkarsh Small Finance Bank Limited.

    S-24/1-2, First Floor, Mahavir Nagar, Orderly Bazar, Near Mahavir Mandir, Cantt. Varanasi-221002

    I, Mr./Miss
    (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 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 person(s) mentioned is/are a 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 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 Age of Proportion by which
    address of nominee(s) the employee nominee the gratuity will be
    shared

    (1) (2) (3) (4)

    1.
    2.
    3.
    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 No. or Serial No., if any
    7. Date of appointment:- 01.01.2017
    [ NEW EIN:- ]
    8. Permanent address:
    Village Thana Sub-division
    Post Office District State

    Place:
    Signature/Thumb-impression of the
    Employee
    Date:

    Declaration by Witnesses
    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 particulars of the above nomination have been verified and recorded in this establishment.
    Employer's Reference No., if any Signature of the employer/Officer authorised
    Designation

    Date: 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

    Note.—Strike out the words/paragraphs not applicable.

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