Notice of Withdrawal of Notice for Excluding Husband from Family

Form ‘E’
[See sub-rule (1) of rule 5]

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 Smt./Mrs. ………………… hereby withdraw the notice dated …………….. whereby I excluded my husband Shri ……………… from my family for the purposes of the Payment of Gratuity Act, 1972. The earlier notice was recorded under your reference No. …………………… dated ………………..

Place :……..
Date :……..			

Signature/Thumb-impression of the employee.

Declaration by witnesses

The above notice of withdrawal was signed/thumb impressed before me.

Name in full and full address of witnesses.	Signature of witness 	
1.	1.	
2.	2.	

Place :
Date :

To

The Controlling Authority,
(Through the employer)
(Name and address of the employer)
For use by the employer 

Received and recorded in this establishment.

Reference No…………				Signature of the employer or officer authorized:

Date :……….. 					   Seal or rubber stamp of the establishment.

To

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

Note : Strike out the words not applicable.