Payment of Gratuity Act, 1972

FORM-N
[See Sub-rule (I) of rule 10]
APPLICATION FOR DIRECTION
BEFORE THE CONTROLLING AUTHORITY UNDER THE PAYMENT OF GRATUITY
ACT, 1972
Application No. Date.............
BETWEEN
Sadhabananda Samal S/o- Late Bhaskar Samal
At- Nigamananda Bihar, Ward No.-01
Po- Bargarh, Dist- Bargarh
Odisha- 768028

AND
The Chairman, Utkal Gramya Bank
Clubpara, Bolangir Head Office
Bolangir- 767001

1. The applicant is an employee of the above mentioned employers nominee of late an employee of the
above mentioned employers legal heir of late Not applicable and employee of the above mentioned
employer, and is entitled to payment of gratuity under section 4 of the payment of Gratuity Act, 1972, on
account of his own aforesaid employees superannuation on 29.02.2012 his own retirement/aforesaid
employees resignation on Not applicable (date) after completion of 34 years 5 months and 3 days years of
continuous service / his own aforesaid employees total disablement with effect from Not applicable due to
accident/disease death of the aforesaid employee on Not applicable (date) .

2. The applicant submitted an application under rule 7 of the Payment of Gratuity Act, 1972 on the
09.09.2016 but the above mentioned employer refused to entertain it/issued a notice date the
.. Under clause .. of sub-rule . of rule
.. offering an amount of gratuity which is less than my due issued a notice dated the
under clause . of rule .. rejecting my
eligibility to payment of gratuity. The duplicate copy of the said notice is enclosed.

3. The applicant submits that there is a dispute on the matter (specify the dispute)
I have been paid less amount of gratuity.
4. The applicant furnished the necessary particulars in the annexure here to and prays the Controlling
Authority may be pleased to determine the amount of gratuity payable to the petitioner and direct the above
mentioned employer to pay the same to the petitioner.

5. The applicant declares that the particulars furnished in the annexure here to are true and correct to the best
of his knowledge and belief.

Date . Signature of the applicant/

thumb impression of the applicant.
 1. Name in full of applicant with full address.
Sadhabananda Samal, S/o- Late Bhaskar Samal, At- Nigamnanda Bihar, Ward No-01
Po- Bargarh, Dist- Bargarh Odisha- 768028
2. Basis of claim
(Death/Superannuation/Retirement/Disablement of employee)
3. Name and address in full of the employee.
Sadhabananda Samal, S/o- Late Bhaskar Samal, At- Nigamnanda Bihar, Ward No-01
Po- Bargarh, Dist- Bargarh Odisha- 768028
4. Marital Status of the employee.
(Unmarried/Married/Widow/Widower)
5. Name and address in full of the employer.
The Chairman, Utkal Gramya Bank, Clubpara, Bolangir Head Office
Po- Bolangir, Dist- Bolangir, Odisha-767001
6. Department/Branch/Section where the employee was last employed (if known).
Utkal Gramya Bank, Udepali, At/Po- Udepali, Dist- Bargarh, Odisha- 768030
7. Post held by the employee with Ticket or Serial No. if any (if known).
Branch Manager with PF no. OR1560/1267
8. Date of appointment of the employee (if known)
26.09.1977
9. Date and cause of termination of service of the employee (Superannuating retirement/
Resignation/Disablement/Death) dated 29.02.2012.
10. Total period of service by the employee.
34 years 5 months 3 days
11. Wages last drawn by the employee.
Basic + DA + Special Allowance = 28900 + 18207 + 1000 = 48107
12. If the employee is dead, date and cause thereof.
Not applicable
13. Evidence/witness in support of death of the employee.
Not applicable
14. If a nominee, No. and date of recording of nomination with the employee.
Not applicable
15. Evidence/witness in support of being a legal heir, if a legal heir.
Not applicable
16. Total gratuity payable to the employee.
Payable Rs. 16, 35,628 already paid Rs. 9, 51, 199 and to be payable 6, 84, 439
17. Percentage of gratuity payable to the applicant as a nominee/legal heir.
Not applicable
18. Amount of gratuity claimed by the applicant.
Rs. 6, 84, 439 and with interest as applicable as per Gratuity Act, 1972.

Place:

Date: Signature/Thumb impression of the

applicant