Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697803653468.pdf (India)
FORM NO.

1 [See rule 53(1)] Nomination for Death-cum-Retirement Gratuity when the Govt.

servant has family and wishes to nominate one member for more than on member thereof.
Ihereby nominate the person/persons mentioned below who is / are member (s) of my family and confer on him/them the right to receive to the extent specified below, any gratuity that may be sanctioned by the Central Govt.
in the event of my death while in service and the right to receive on my death, to the extent specified below any gratuity which having become admissible to me on retirement may remain un-paid at my death, ORIGINAL NOMINEE (S) ALTERNATE NOMINEE (S) Name and address of nominees/ nominee Relationship With Govt.
servant Age Amount of share of gratuity payable to each* Name and address, relationship and age of the person /or persons, if any to whom the nominee shall pass in the event of nominee predeceasing the Govt.

servant but before receiving payment of gratuity Amount of share of gratuity payable to each** * This column should be filled in so as to cover the whole amount of gratuity.
** The amount/share of the gratuity shown in this column should cover the whole amount / share payable to the original nominee (s).

This nomination supersedes the nomination made by me earlier on which stand cancelled.

Note .

(1) The Govt.

servant shall draw lines across the blank space below the last entry to prevent the insertion of any name after he has signed.

(2) Strike out which is not applicable.


Dated this day of .at.
Witnesses to sign here: -- 1 2 3 Signature of Applicant.
(TO BE FILLED IN BY THE HEAD OF OFFICE/ACCOUNTS OFFICER) Nomination by Designation .
Office.. Signature of Head of Office/Accounts Officer