Notice of Excluding Husband from Family

Form ‘D’
[See sub-rule (1) of rule 5]

From …………………

1. Name of the female employee :
2. Name or description of establishment where employed :
3. Post held with Ticket or Serial No., if any:
4. Department/Branch/Section where employed:
5. Permanent address :

Take notice that I, Shrimati …………………. desire to exclude my husband Shri ……………. from my family for the purposes of the Payment of Gratuity Act, 1972.

Place :……..
Date :……… 	

Signature/Thumb Impression of the employee.

Declaration by witnesses

The above notice was signed/thumb-impressed before me
Name in full and full address of witnesses					

Signature of witnesses

1.				1.
2.				2.

Place : ………
Date :……….

To

The Controlling Authority,
(Through the employer)
(Name and address of the employer here)

For use by the employer

Received and recorded in this establishment

Date : 	……….							
Signature of the employer or
An officer authorized in this
Behalf by the employer.

To

1. ……………………… (Employee)
2. The Controlling Authority

Note.- Strike out the words not applicable.