NOKIA SIEMENS NETWORKS PVT LTD

EMPLOYEES GROUP GRATUITY SCHEME

L5, 9th Floor, Manyata Embassy Business Park, Hebbal Nagavara outer ring road, Nagavara, Bangalore – 560 045

The Trustees, Date: ___________

Gratuity Claim Form from LIC India

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 : Rs.

Tax Exemption on Gratuity : Rs.
Tenure :

2. Name of Previous Employer 2:

Gratuity Received other than NSN : Rs.

Tax Exemption on Gratuity : Rs.
Tenure :

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