Take notice that I, Shrimati .............................. hereby withdraw the notice dated whereby ....................... I exclude my husband Shri ........................... from my family for the purposes of the Payment of Gratuity Act, 1972. The earlier notice was recorded under your reference No. .............................. dated ............................

Place................................................

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

................................................

Signature/Thumb impression of the employee.

Declaration by witnesses

The above notice of withdrawal was signed/thumb impressed before me.

Name in full and full address of witnesses.

Signature of witnesses.

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

1.

...........................................................

2.

.........................................................

2.

...........................................................

Place....................................

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

To

The Controlling Authority (Through the employer)

[Name and address of the employer]

For use by the employer

Received and recorded in this establishment.

Reference No.

..........................................

Signature of the employer or

officer authorised.

Seal or rubber stamp of the establishment.

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

To