A Maheswararao Form F

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THE PAYMENT OF GRATUITY RULE, 1972.

FORM F
(See sub rule (1) of rule 6)
Nomination

Fed Bank Financial Services Limited


To:

1 Shri/Shrimati/ Kumari ATTHILIUMA DURGA MAHESWARARAO


whose particulars are given in the statement below, hereby nominate the person(s) mentioned
my credit in
below tO receive the gratuity payable after my death as also the gratuity standing to payable
amount has become payable, or having become has
the event of my death before that indicated
the said amount of gratuity shall be paid in proportion
not being paid and direct that
against the name(s) of the nominee(s).
family within the
2 Thereby certify that the person(s) mentioned is/are member(s) of my
meaning of clause(h) of section 2 of the Payment of Gratuity act, 1972.
section 2 of of the said
3 Thereby declare that I have no family within the meaning of clause(h) of
act.

4. (a) My father/ mother/ parents is/ are not dependent on me.


husband.
(b) My husband's father/ mother/ parents is/ are not dependent on my
to the controling
5 Ihave excluded my husband from my family bya notice dated the said act.
authority in terms of the provision to the clause(h)of section 2 of the
6. Nomination made herein invalidates my previous nominations.

NOMINEE(S)
Name in full with address Relationship Age of the Proportion by
of the nominee(s) with the nominee which the gratuity
will be shared
Sr No. employee
(2) (3) (4)
(1)
1.
47 So).

2 Mo7tleR
A:

STATEMENT

1.
HINDU
Religion
2 Sex
MALE
Atthili Uma Durga Maheswararao

3 Name of Employee in full

4. Whether unmaried / married/ widow /widower


5. Department/branch/section where employed

6 Post held with ticket or serial number if any

13-Mar-2024
7 Date of appointment
DOOR No 21-10/2-113 VIJAYADURGANAGAR, BUDAMERU MADHYA KATTAVIJAYAVWADA
8 Permanent Address

Thana Sub division


Villagevj Ay 4waDA
Post office AyANARay4 District State UIjAy Aw APA

Place: v2]Ayaw ADA Signaturettumb impression


Date: of the employee.

DECLARATION BY WITNESS

Nomination signed/thumb impressed before me.


Name and full address of the witnesses.
Signatufebf the witnesses
1 1.
2
Joun
Place:VAYAWAD4
Date:

CERTIFICATE BY THE EMPLOYER

recorded in this establishment.


Certify that the particulars of the above nomination have been verified and
Employers reference No. If any:

Signature of the employer/ officer authorized.

Designation :
Date
Name and address of the establishment or
rubber stamp therof

ACKNOWLEDGMENT BY THE EMPLOYEE

me and duty certifjed, by the employer:


Received the duplicate copy of nomination in form "F" filed by

Signatture of the employee:


Date

Note: Strike out the words/paragraphs not applicable.

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