• 1. Shri/ Shrimati/ Kumari ……………[Na m e in full h ere] whose particulars a re given in the statement below, hereby give notice that the nomination filled by m eon [date] and recorded under your reference No. ……………… dated …………….. s h a ll s tan d modified in the following manner:

[Hear give details of the modifications in tended]

State m e n t

Place Signature/ Thumb impression

Date of the employee

Declaration by witnesses

Modification of n om in a t ion signed/ thumb impressed before me. Name in full and full Signature of witnesses. Address of witnesses .

1 . 1 .

2 . 2 .

Place Date

Certificate by the employ er

Certified that the above modification have been recorded.

Employer,s reference No., if any. Signature of the employer/Officer authorized

Designa t ion

Name and address of the

Acknowledgement by the employee

Received the duplicate copy of the notice for modification in form ‘H’ filed by m eon

……………….. duly certified by the employer.

Date Signature of the employee

Different types of forms of gratuity

Establishment or rubber stamp thereof.