ICF,Chennai-38 FORM 4
[See Rule 74 (i)] OF RAILWAY SERVICES (PENSION) RULES 1993
NOMINATION FOR DEATH-CUM-RETIREMENT GRATUITY
(When the Railway Servant has a family and wishes to nominate one member or more than one member thereof)

I ....................... hereby nominate the person/persons mentioned below ,who is/are member(s)of my family,and confer on them the right to receive, to the extent specified below,any gratuity that may be sanctioned by 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 unpaid at my death:-
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Original Nominee(s) Alternate nominee(s)
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Name & address Relationship Age Amt. or Address and relationship of
of nominee / with the share of the person or persons,if any
nominees Railway gratuity to whom the right conferred
Servant payable on the nominee shall pass in
to each* the event of the nominee pre-
deceases the Rly.servant or
the death of the Rly.servant
but before receiving payment
of the gratuity.
Amountof
Share of
gratuity
payable
to each @
(1) (2) (3) (4) (5) (6)
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1.

2.

3.

{ P.T.O }
_______________________________________________________________cut_here__

Proforma for acknowledgement, the receipt of nomination form by the Head of Office/Accounts Officer
To
......................
The receipt of your nomination dated the .............../cancellation dated the ............... of the nomination made earlier in respect of Death-cum-Retirement Gratuity in Form ............. is hereby acknowledged. The same has been duly placed on record.

.....................................
Signature of the Head of Office/Accounts Officer

Place............
Designation ..............
Dated............
{ P.T.O }

(1) (2) (3) (4) (5) (6)
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4.

5.

and so on ------------------------------------------------------------------------
This nomination supersedes the nomination made by me earlier, on ........ (date) which stands cancelled.

Note-(1)The Rly. 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 whichever is not applicable.

Date this............. day of .................20

Witnesses to signature

1........................................

2........................................

SIGNATURE OF RAILWAY SERVANT
Emp.No:
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This column should be filled in so as to cover the whole amount of gratuity.
@The amount/share of gratuity shown in this column should cover the whole
amount/share payable to the original nominee(s).

(To be filled in by the Head of Office in case of a non-gazetted Rly.servant)

Nominated by ..................
Signature of Head of Office................

Designation ................... Dated..........

Office ................... Designation ................

____________________________________________________________________________

Note:- The Rly. servant is advised that it would be in the interest of the
nominee(s) if copies of the nominations and the related notices and
acknowledgement are kept in safe custody so that they may come into
possession of the beneficiaries in the event of his death.