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 employer concerned 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 employees superannuation on......... /his [Date] own retirement/aforesaid employee's resignation on....... After completion [Date] of....years of continuous service/his own/aforesaid employee's total disablement with effect from....... [Date] due to accident/disease/death of the aforesaid employee on...... 2. The applicant submitted an application under Rule ........ of the payment of Gratuity Act, 1972 on the ........ but the above mentioned employer refused to entertain it/issued a notice dated the ........ Under clause....... of sub-Rule of Rule ....... offering an amount of gratuity which is less than me due/issued a notice dated the ....... Under clause ....... of sub-Rule ..... of Rule ..... rejecting my eligibility to payment of gratuity. The duplicate copy of the said notice is enclosed. 3. The applicant submits that there is a dispute on the matter. 4. The applicant furnishes 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. [Specify the dispute] Page 77 of 151 Date Signature of the applicant/ Thumb Impression of the applicant. Page 78 of 151 Annexure 1. Name in full of applicant with full address. 2. Basis of claim: [Death/Superannuation/Retirement/Resignation / 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 employer. 6. Department/Branch/Section where the employee was 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. [Superannuation/ 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 there of. 13. Evidence/ witness in support of death of the employer. 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 Signature / Thumb Impression of Date the applicant. Note: Strike out the words not applicable. Page 79 of 151
