FORM 'K'

See sub-rule (3) of Rule 7

Application for Gratuity by a Legal Heir

To,

(Give here the name or description of the establishment with full address)

Sir/Gentlemen,

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, as a legal heir of late

(Name of the Employee)

who was an employee of your establishment and died on

the without making any nomination. The gratuity is payable on account of the death of the aforesaid employee while in service/superannuation of the aforesaid employee on

the retirement or resignation of the aforesaid employee

on the after completion of years of service/total

disablement of the aforesaid employee due to accident or disease while in service with effect from

the Necessary particulars relating to my claim are given in the Statement below:

Statement

1. Name of applicant legal heir

2. Address in full of applicant legal heir

3. Marital status of the applicant legal heir (unmarried/married/widow/widower)

4. Name in full of the employee

5. Relationship of the applicant with the employee

6. Religion of both the applicant and the employee

7. Date of appointment and total period of service of the employee

8. Department/Branch/Section where the employee worked last

9. Post last held by the employee with Ticket or Sl. No., if any

10. Total wages last drawn by the employee

11. Date and cause of termination of service of the employee (death or otherwise)

12. Date of death of the employee and evidence/witness in support thereof

13. Total gratuity payable to the employee

14. Percentage of the gratuity claimed

15. Basis of the claim and evidence/witness in support thereof

2. I declare that the particulars mentioned in the above statement are true and correct to the best of my knowledge and belief.

3. Payment may please be made in cash/open or crossed bank cheque.

4. As the amount payable is less than Rupees one thousand, I shall request you to arrange for payment of the sum due to me by postal money order at the address mentioned above, after deducting postal money order commission therefrom.

Yours faithfully,

Signature/Thumb-impression of applicant

legal heir.

Place:

Date:

Note.—Strike out the words not applicable.

Different types of forms of gratuity