FORM NO. 40A

FORM NO. 40A

[See rule 67A/rule 101A]*

Form of nomination

…………………………..……Provident Fund/ ……..........................................Gratuity Fund*

[name of fund]

 [name of fund]

1. Name of employee ………………………………………........Surname ........................................

[in block letters]

2. Sex ................................................................................................................................. .....................

3. Religion ..................................................................................................................................................

4. Father’s name ........................................................................................................................................

5. Husband’s name ....................................................................................................................................

[for married woman only]

6. Marital status .........................................................................................................................................

[whether unmarried, married, widow or widower]

7. Date of birth: Day ..................................Month ...............................Year ..............................

8. Permanent address:

Village ............................... …Thana; …................................ Taluk/Sub-Division ..............................

Post Office ........................................ District ........................................ State

........................................

I hereby nominate the person(s) mentioned below to receive the

*amount that may stand to my credit in the provident fund

*amoiunt of gratuity  in the event of my death before that amount becomes pay-

able or, having become payable, has not been paid, and direct that the said amount shall be distributed

among the said person(s) in the manner shown against their names :

Name and address of Nominee’s relationship Age of nominee *Amount or share

nominee or nominees with the employee

 of accumulations

in the provident

fund/*amount

or share of

gratuity to be

paid to each

nominee$

1

 2

 3 4

*1. Certif ied that I have no family and should I acquire a family hereafter, the above nomination should

be deemed as cancelled.

*2. Certified that my father/mother/sister(s)/minor brother(s) is/are dependent upon me.

Dated this ........................................ day of ......................................…....... at ....................

………………………………

Signature of employee

Two witnesses to signature

1.

2.

Certified that the above declaration has been signed by Shri/Shrimati ........................................

 .

before me after  *he / she has read the entries

*the entries have been read over to him / her by me

Date ....................

 …………..……………………

Signature of the trustee or any

person authorised by the

trustees in this behalf

*Delete the inapplicable words.

$ This column should be filled in so as to cover the whole of the amount that may stand to the credit of the

employee in the provident fund or the whole of the amount of gratuity that may be payable in the event of his

death.

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FORM NO. 40A (English)

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