NOMINATION FORM - GRATUITY (Applicable to all

employees)
FORM-F
(See Sub-Rule (1) of Rule (6)
To

Wipro Limited
Doddakannelli
Sarjapur Road
Bangalore-560 035
Fill in Your Name as per Wipro Records
1. Sri/Smt./Kumari F U L L N A M E whose
particulars are given in the statement below, hereby nominate 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).

2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of clause(h) of section
2 of the Payment of Gratuity Act, 1972.
Clause (h) - Family definition
3. I hereby declare that I have no family within the meaning of clause (h) of section 2 of the said act. Male Employee:
a ) Wife
b) Children
c) Dependent Parents
4 (a) My father/mother/parents is/are not dependent on me. d) Dependent Parents of his Wife
e) Deceased son's widow and children
(b) My husband’s father/mother/parents is/are not dependent on my husband.
2. Female Employee:
a) Husband
5. I have excluded my husband from my family by a notice dated the to the Controlling b) Children
c) Dependent Parents
Authority in terms of the proviso to clause (h) of Section 2 of the said Act. d) Husband's dependent parents
e) deceased son's widow and children

6. Nomination made herein invalidates my previous nomination. If these dependents are not nominated
in the below table please tick for a & b
these options
NOMINEE(S)
Name in full with Relationship Proportion by which
Age of
Sl. full address of with the the gratuity will be
Employee Nominee
No. nominee(s) shared
1 2 3 4

Nominate the members as per the family

definition provided above.

1) FILL IN THE NAME OF THE NOMINEE

2)

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 3)

4)

STATEMENT
1. Name of employee in full : Fill in Your Name as per Wipro Records

Employee Gender
2. Sex :

3. Religion : Employee Religion

4. Whether unmarried / married widow Fill in Marital status

/ widower / divorcee
5. Department / Branch / Section where Current department
employed :
6. Post held with ticket / employee Fill in your Employee Number
number :

7. Date of appointment : Date of Joining with Wipro

8. Permanent address : Fill in residential Permanent address

This is not a This is not a

Village : Thana : mandatory field mandatory field
Sub-division :

District : State :
Post Office :
Place : ....................................................

Signature / Thumb impression

Date : .................................................... of the employee

DECLARATION BY WITNESS
Nomination signed / thumb impressed before me

Name in full :
Signature of witness :

Address of witness : Any Co-employee can sign

as witness
1
1.

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2 2.
FOR OFFICE USE ONLY

Please leave this field black

CERTIFICATE BY THE EMPLOYER and proceed with upload

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer’s Reference No. if any

Date : Signature of the employer/officer authorised

Designation
Name & address of the establishment or
rubber stamp thereof

ACKNOWLEDGEMENT BY THE EMPLOYEE Please leave this field

black and proceed with
upload

Received the duplicate copy of nomination in Form-F filled by me and duly certified by the employer.

Date...................................... Signature of the employee

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