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, 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 here of late _________________________ (name of the employee) who was an employee of your establishment and died on the ________________ with out making any nomination. The Gratuity is payable on account of the aforesaid employee while in service / superannuating of the aforesaid employee on ___________________________________ after completion of ____________________ years of service / total disablement of the aforesaid employee due to accident or discase while in service with effect from ___________________ Necessary particulars relating to my claim are given in the statement below: STATEMENT 1. Name of applicant legal heir : 2. Address in full or applicant / legal heir : 3. Martial status of the applicant : (unmarried / married/widow/widower) 4. Name in full of the employee : 5. Relationship of the applicant with the employee : 6. Rligion of both 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 serial 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 of the employee: 14. Percentage of the gratuirty claimed : 15. Basis of the claim and evidence/ witness in support thereof : I declarte that the perticulars mentioned in the above statement are ture and correct to the best of my knoledge and belife. Payment may please be made in cash/open or crossed bank Cheque. As the amount payable is less than rupee one thousend, I shall request you to arrange for payment of the sum due to by Postal money Order at the address mentioned above, after deducting postal money order commissions therefrom. Yours faithfully, Place : Date : Signature/thumb-impression of applicant/Legal heir
