Note.- The Portion not applicable to be deleted.

FORM 'T'

[See rule 19]

Application For Recovery Of Gratuity

Before the Controlling Authority under the Payment of Gratuity Act, 1972.

Application No ........................................

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

Between

......................................................................................................................................................................................................................................... [Name in full of the applicant with address]

And

.................................................................................................................................................................................................................................... [Name in full of the employer with full address]

The applicant is an employee of the above-mentioned employer/a nominee of late ............ an employee of the above mentioned employer/a legal heir of late ......................., an employee of the above mentioned employer, and you were pleased to direct the said employer in your notice dated the .............................. under rule ............................... of the Payment of Gratuity (Central) Rules, 1972 for payment of a sum of Rs .......... as gratuity payable under the Payment of Gratuity Act, 1972.