Schedule LIII-Form No.350 (New) O.C.S.(PENSION) FORM 4 (See rule 53 read with F.D. Resolution No.29826, dated the 9th July, 1992) NOMINATION FOR DEATH OR RETIREMENT GRATUITY When the Government servant has no family and wishes to nominate one person or more than one person I ............ having no family, hereby nominate the person/persons mentioned below and confer on him/them the rights to receive, to the extent specified below, any gratuity the payment of which may be authorized by the State Government in the event of my death while in service and the right to receive on my death to the extent specified below, any gratuity which having become admissible to me on retirement may remain unpaid at my death- Original nominee(s) Alternate nominee(s) Names and address of nominee/nominees Relationship with the Government servant Age *Amount or share of gratuity payable to each Name, address, relationship and age of the person or persons, if any, to whom the right conferred on the nominee predecessing the Government Servant or the nominee dying after the death of the Government servant but before receiving payment of gratuity ** Amount or share of gratuity payable to each. 1 2 3 4 5 6 * This column should be filled in so as to cover the whole amount of the gratuity. ** The amount/share of the gratuity shown in this column should cover the whole amount/share payable to he original nominee(s). (2) This nomination supersedes the nomination made by me earlier on ..... which stands cancelled. NOTE-(i) The Government servant shall draw lines across the blank space below the last entry to prevent the insertion of any name after he has signed. (ii) Strike out which is not applicable. Dated this ......... Day of ........ 20... at ..... Two witnesses to signature: 1. 2. Signature of Government Servant (To be filled by the Head of Office) Nomination by: .......... Signature of Head of Office Designation : ........... Date Office : .............. Designation Pro forma for acknowledging the receipt of the nomination form by the Head Office To Sir, In acknowledging the receipt of your nomination, dated the .......... /cancellation dated the ....... Of the nomination made earlier in respect of gratuity in Form .... I am to state that it has been duly placed on record. Place: Signature of Head of Office /Authorised Authority Date: Designation NOTE:-The Government servant is advised that it would be in the interest or his nominees if copies of the nomination and the related notices and acknowledgements are kept in safe custody so that they may come into the possession of the beneficiaries in the event of his death.
