Payment of Gratuity Act,1972 FORM-N [See Sub-rule (I) of rule 10] APPLICATION FOR DIRECTION BEFORE THE CONTROLLING AUTHORITY UNDER THE PAYMENT OF GRATUITY ACT, 1972. Application No. date BETWEEN (Name in full of the applicant with full address) AND (Name in full of the applicant with full address) The applicant is an employee of the above-mentioned employer's nominee of late an employee of the above mentioned employer's legal heir of late.......... and employee of the above mentioned employer, and is entitled to payment of gratuity under section 4 of the payment of Gratuity Act, 1972, on account of his own aforesaid employee's superannuation on ......... his own retirement/aforesaid employee's resignation on .............(date) after completion of .......... years of continuous service /his own aforesaid employee's total disablement with effect from........... due to accident/disease death of the aforesaid employee on .............(date)......... 2. The applicant submitted an application under rule........of the Payment of Gratuity Act.1972 on the ........but the........abovementioned employer refused to entertain it/issued a notice date the.......under clause.......of sub-rule.........or rule ...........offering an amount of gratuity which is less than my due issued) a notice dated the ..........under clause........of rule........rejecting my eligibility to payment of gratuity. The duplicate cope of the said notice is enclosed. 3. The applicant submits that there is a dispute on the matter (specify the dispute) 4. The applicant furnished the necessary particulars in the annexure hereto and prays that the Controlling Authority may be pleased to determine the amount of gratuity payable to the petitioner and direct the above-mentioned employer to pay the same to the petitioner. 5. The applicant declares that the particulars furnished in the annexure hereto are true and correct to the best of his knowledge and belief. Date...... Signature of the applicant/thumb impression of the applicant. 1. Name in full of applicant with full address. 2. Basis of claim (Death/superannuating/Retirement/Disablement of employee) 3. Name and address in full of the employee. 4. Marital status of the employee (Unmarried/married/widow/widower) 5. Name and address in full of the employee 6. Department/Branch/Section where the employee was last employed (if known) 7. Post held by the employee with Ticket or Serial No. if any (if known). 8. Date of appointment of the employee (if known) 9. Date and cause of termination of service of the employee (Superannuating retirement/resignation/disablement/death) 10. Total period of service by the employee. 11. Wages last drawn by the employee. 12. If the employee is dead, date and cause thereof. 13. Evidence/witness in support of death of the employee. 14. If a nominee, No. and date of recording of nomination with the employer. 15. Evidence /witness in support of being a legal heir, if a legal heir. 16. Total gratuity payable to the employee (if known). 17. Percentage of gratuity payable to the applicant as a nominee/legal heir. 18. Amount of gratuity claimed by the applicant. Place: Date: Signature/ thumb impression of the applicant.
