FORM 4 – Application for retirement Gratuity i.ro. missing Government servant
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.