Rule Form III Form III
- Chapter
- Annexures · Forms and Appendices
- Text as on
- As notified 08 May 2026
FORM-III [(See rules 32 (1),(2), (3) and (4)] [For the purpose of Chapter-V]
Nomination/Fresh Nomination/Modification of Nomination (Strike out the words not applicable)
Sl. No. Details of the employee:
1. Name of employee in full
2. Father`s/Spouse`s name
3. Date of Birth (- -/- -/- - - -)
4. Universal Account Number(if available):
5. Sex
6. Religion
7. Whether unmarried/married/widow/widower
8. Department/Branch/Section where employed
9. Post held with Ticket No. or Serial No., if any
10. Date of appointment
11. Date of superannuation
12. Permanent address:
Village:
Post-Office:
Thana:
Sub-Division:
District:
State:
Pin-Code:
E-mail ID:
Mobile Number:
To..................................................................................................................... ................. (Give here name or description of the establishment with full address)
I, Shri/Shrimati/Kumari.......................................(Name in full here)whose particulars are given in the statement below, hereby nominate the person(s) mentioned below/ have acquired a family within the meaning of clause (33) of section 2 of the Code on Social Security, 2020 (36 of 2020) with effect from the .....................(date here) in the manner indicated below and therefore nominate afresh the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).
or I, Shri/Shrimati/Kumari.................................(Name in full here) whose particulars are given in the statement below, hereby give notice that the nomination filled by me on date ............ and recorded under your reference No................dated................... shall stand modified in the following manner:-
*Strike out unnecessary portion. Nominee(s)
S.No. Name in full with full Relationship Age of Aadhaar No. of the Proportion by
address of with nominee nominee which nominee(s) the gratuity will be the employee shared 1. 2. 3. So on
DECLARATION
1. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause (33) of section 2 of the Code on Social Security, 2020 (36 of 2020).
2. I hereby declare that I have no family within the meaning of clause (33) of section 2 of the said Code.
3 (a) My father/mother/parents is/are not dependent on me.
(b) My husband's father/mother/parents is/are not dependent on my husband.
4. I have excluded my husband from my family by a notice dated the.................. to the competent authority in terms of clause (33) of section 2 of the said Code.
5. Nomination made herein invalidates my previous nomination.
Manner of acquiring a Family
(Here give details as to how a family was acquired, i.e., whether by marriage or parents being rendered dependent or through other process like adoption)
Place: Date:
Signature/Thumb-impression of the Employee
Certificate by the Employer
Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any Signature of the employer/Officer authorised Designation Date: or Name and address of the establishment
rubber stamp thereof.
Acknowledgement by the Employee
Received the duplicate copy of nomination in Form-III filed by me and duly certified by the employer.
Date: ......................
Signature of the Employee