FORM 4. Application for retirement Gratuity in respect of missing Government servant: CCS (Payment of Gratuity under NPS) Rules, 2021

FORM 4. Application for retirement Gratuity in respect of missing Government servant: CCS (Payment of Gratuity under NPS) Rules, 2021

FORM 4
Application for the Grant of retirement Gratuity in the case of missing Government servant
[See sub-rule (2) of rule 33 ]

(To be filled in separately by each claimant and in case the claimant is minor, the form should be filled in by the guardian on his/her behalf. Where there are more than one minor and one guardian for all of them, the guardian should claim gratuity in one Form on their behalf)

1. Details of missing Government servant:

Name and designation	Date of report	DD/MM/YYYY
Office/Department/Ministry in which the deceased served last

2. Details of claimant(s):

Sl. No.	Name	Date of birth (DD/MM/YYYY)	Relationship with the missing Govt. servant	Postal address
1.
2.
3.

3. In case the claimant(s) is/are minor or suffering from disorder or disability of mind, including mental retardation, details of guardian:

Name	Date of birth (DD/MM/YYYY)	Relationship with the minor/mentally disabled	Relationship with the missing Govt.Servant	Postal address

4. Details of bank:

Bank’s Name

A/c No.

IFS Code

Place:

Date:

(Signature of the claimant/guardian)
Mobile no.: … …. …. ….. ….. ….

Enclosure:
a. Copy of report of missing in Police Station.
b. Guardianship Certificate/ Indemnity Bond and Date of Birth Certificate in case the claimant is a minor.
c. Guardianship Certificate/ nomination and Medical Certificate in case the claimant is mentally disabled.

FORM 4 – Application for retirement Gratuity Hindi & English PDF

Also Read: FORM 5. Assessment and Authorisation of Gratuity when a Government Servant is missing: CCS (Payment of Gratuity under NPS) Rules, 2021