FORM 'I' [See Sub-Rule (1) of Rule 7] Application of gratuity by an employee To .......... ......... [Give here name or description of the Establishment with full address] Sir/Gentlemen, 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 on account of my superannuation/retirement/resignation after completion of not less than five years of continuous service/total disablement due to accident. Total disablement due to disease with effect from the ...... Necessary particulars relating to my appointment in the establishment are given in the statement below: Statement 1. Name in full. 2. Address in full. 3. Department/Branch/Section where last employed. 4. Post held with Ticket No. or Serial No., if any, 5. Date of appointment. 6. Date and cause of termination of service. 7. Total Period of service. 8. Amount of wages last drawn. 9. Amount of gratuity claimed. I was rendered totally disabled as a result of [Here given the details of the nature of diseases or accident] The evidence/ witnesses in support of my total disablement are as follows. [Here give Details] Page 81 of 151 Payment may please be made in cash/ open or crossed bank cheque. As the amount of gratuity payable is less than rupees one thousand, I shall request you to arrange for payment of the sum due to me by postal Money order at the address mentioned above after deducting postal money order commission there from. Yours faithfully, Place Date Signature / Thumb Impression of the applicant. Note: 1. Strike out the words not applicable. 2. Strike out paragraph or paragraphs not applicable. Page 82 of 151
