FORM NO. 40A
[See rule 67A/ rule 101A]
Form of nomination
______________________________________________________________________________ [name of fund]Provident
Fund /___________________________________________________________ [name of fund]Gratuity Fund
1. Name of employee __________________[in block letters] Surname _______________________________________
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 Taluka/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 in the amount of gratuity event of my death before that amount becomes payable 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
or nominees
Nominee's relationship with the
employee
Age of nominee Amount or share of accumulations in the
provident fund/ amount or share of gratuity to be
paid to each nominee
1 2 3 4
1. Certified 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 _________
Two witnesses to signature ______________________________
1. ______________________________________________________ Signature of employee
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.