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CG_Gratuity_Form F (1)

The document is a Gratuity Nomination Form for Radheshyam Dasarath Choubey, nominating his spouse, Sushila Choubey, as the sole beneficiary for gratuity benefits. It includes details such as the beneficiary's relationship, date of birth, and address, along with declarations and certifications required by the employer, Capgemini Technology Services India Limited. The form also contains sections for witness signatures and acknowledgment by the employee.

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radheshyamchoubey85
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4 views

CG_Gratuity_Form F (1)

The document is a Gratuity Nomination Form for Radheshyam Dasarath Choubey, nominating his spouse, Sushila Choubey, as the sole beneficiary for gratuity benefits. It includes details such as the beneficiary's relationship, date of birth, and address, along with declarations and certifications required by the employer, Capgemini Technology Services India Limited. The form also contains sections for witness signatures and acknowledgment by the employee.

Uploaded by

radheshyamchoubey85
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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(This form is not applicable for Interns)

Gratuity Nomination Details

Gratuity Benefit
1 2 3 4 5

Beneficiary Name
Sushila Choubey

Beneficiary Relationship

Spouse

Beneficiary Date of Birth


01/01/1991

Beneficiary Guardian Name


Navnath Dubey
(If the nominee is a minor)

Beneficiary Address Flat no. 504 Samarth


Residency, Narhe,
Pune-411041.
Proportion of Lumpsum% Maharastra
100
(This form is not applicable for Interns)
FORM F
See Sub−rule (1) of Rule 6
Nomination

To,
Capgemini Technology Services India Limited Plant.2, Block A, Godrej IT
Park, Godrej & Boyce compound, LBS Marg, Vikhroli (West),
Mumbai−400079

I, Shri/ Srimati/Kumari Choubey


Radheshyam Dasarath

Whose recently 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.

1. 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.

2. I hereby declare that I have no 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/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 provision to
clause (h)of

5. Nomination made here in invalidates my previous nomination.

Beneficiary Name in full with full address Beneficiary Relationship with the Beneficiary Date of Birth Proportion of Lumpsum %
employee

Flat no. 504 Samarth Spouse 01/01/1991 100


Sushila Choubey
Residency, Narhe,
Pune-411041.
Maharastra

Statement

1. Full Name of member : Choubey


Radheshyam Dasarath
:
2. Sex : Male
3. Religion ::
4. Whether Unmarried/ married/widow/widower : Married
:
5. Department/Branch/Section where employed
6. Post held with Ticket No. or Serial No., if any :

7. Date of Appointment : 06/26/2025


8. Permanent Address
Village: Thana: Subdivision:
Bokaro Steel City Quator no-3-249 India

Post Office: District: State:


827001 Jharkhand 30235

Place: Bangalore
Date: signature/Thumb-impressed of employee
(This form is not applicable for Interns)

Declaration by Witnesses

Nomination signed/thumb-impressed before me


Name in full and full address of witnesses. Signature of Witnesses.
1. 1 .____________________________________

2. 2. _____________________________________

Bangalore
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 authorized

Designation

Date:
Name and address of the establishment or rubber stamp thereof.
Capgemini Technology Services India Limited Plant.2, Block A,
Godrej IT Park, Godrej & Boyce compound, LBS Marg, Vikhroli
West), Mumbai−400079

Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

04/28/2025
Date: Signature of the Employee
Electronically signed by:
Radheshyam Dasarath Choubey
Note− Strike out the words/paragraphs not applicable.

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