FORM - I (See Rule 53 (I) ) Nomination for Retirement Gratuity / Death Gratuity. When the Government servant has a family and wishes to nominate one member or more than one member, thereof. I,..................., hereby nominate the person / persons mentioned below who is/are members of my family and confer on him/them the right to receive to the extent specified below, any gratuity the payment of which may be authorized by the Central Government in the event of my death while in service and the right to receive on my death to the extend specified be or any gratuity which having become admissible to me on retirement may remain unpaid at my death - ORIGINAL NOMINEE (S) ALTERNATE NOMINEE (S) Names & addresses of nominee / nominees Relationship with the Govt. servant Age Amount or shares of gratuity payable to each. Name, address, relationship & age of the person of persons, if any to whom the right conferred on the nominee predeceasing the govt. servant or the nominee doing after the death of the govt. servant but before receiving payment of gratuity. Amount or share of gratuity payable to each. This nomination supercedes the nomination made by me earlier on ___________________ which stands cancelled. NOTE - (i) The Government servant shall draw lines cross 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______________________200___ at Witnesses to Signature : 1._______________________________________ 2._______________________________________ Signature of Govt. Servant. (To be filled by the Head of Office) Nomination by____________________________ Designation_______________________________ Office____________________________________ Signature of Head Office with date Designation_________________________
