NOKIA SIEMENS NETWORKS PVT LTD

EMPLOYEES GROUP GRATUITY SCHEME

The Trustees,

Date: ___________

Gratuity Claim Form

Dear Sir,
Please send me gratuity payment cheque at the following address after deduction on Income
Tax under Income Tax Act.
1. Name of Member

2. Name of Father / Husband

3. Address of Member

4. Contact Number and Email

4. Employee Code No.

5. PAN Number

6. Last drawn monthly Basic

:
(Enclose a copy of last month pay slip to verify Basic)
7. Date of Joining

8. Date of Leaving

:
(SIGNATURE OF MEMBER)

Deceased Case Death Certificate issued by Municipal Authority / Gram Panchyat.

Disability Certificate from approved physician
In all other cases - This claim form only

Gratuity Tax Exemption

(From No. 10E)

Form for claiming gratuity tax relief under section 89(1) by the year ending 31st March , 20.
Employee Name
Employee ID
Permanent Account Number
Date of Birth
Date of Joining in NSN

:
:
:
:
:

A . Furnish the detail, if Gratuity Exemption has been availed from previous employer
1. Name of Previous Employer 1 :
Gratuity Received other than NSN
Tax Exemption on Gratuity
Tenure

: Rs.
: Rs.
:

2. Name of Previous Employer 2:

Gratuity Received other than NSN
Tax Exemption on Gratuity
Tenure

: Rs.
: Rs.
:

3. Enclose all previous employer Form 16 prior to NSN Joining (Mandatory)

B . I have not taken Gratuity exemption from my previous employer as if now during my
Service tenure.
I do declare that, is stated above is true to the best of my knowledge and belief and also undertake to
indemnify the company for any loss / liability that may arise in the event of above information being
incorrect.

Place..
Date .

Signature of the employee

Note : It is an offence to make a false declaration for the purpose of obtaining a Tax exemption