Social Security Form IV: employee gratuity claim

Application to the employer for gratuity by an employee, nominee or legal heir; choose the correct claimant route.

(See rule 33(1) · Social Security (Central) Rules, 2026 · Central-sphere scope

Download and read the completed example

Completed fictional employee gratuity claim for Sahyadri Illustration Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001. It illustrates the prescribed fields without executing a signature or official act.

Fictional, unsigned completed illustration. It demonstrates this form’s fields; it is not a filed return, medical opinion, official order or proof of an actual transaction.

When and how this form is used

Form IV goes to the employer. Its employee, nominee and legal-heir alternatives are different routes; strike out or mark inapplicable alternatives honestly.

For the illustrated monthly-rated employee, the ordinary 15/26 calculation applies to the assumed relevant monthly wage and completed years. The statutory wage definition, service exceptions and any applicable ceiling must be tested on the actual facts.

The completed fields

Claimant and employment particulars

Prescribed field / section	Completed fictional entry
To employer	Sahyadri Illustration Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001
Applicant route / name / address	Employee route selected: Arun Mehta (fictional), 8 Example Lane, New Delhi 110001; married
Ground	Retirement on 30 September 2026 after continuous service from 1 October 2016
Department / post	Finance / accounts officer
Nominee / legal-heir route / death proof	Not applicable; employee alive and applying personally
Appointment / termination / service	1 October 2016 / 30 September 2026 / 10 completed years
Last monthly wages	₹52,000; sample assumes this is the relevant statutory wage base
Gratuity / share	₹3,00,000; employee claims 100%
Payment account	Account holder Arun Mehta; [synthetic account and IFSC; not payable]
Place / date / execution	New Delhi, 5 October 2026; Signature / seal / certification not executed; typed name is an illustration only

Supporting records and reconciliation

Use the appointment/service records, retirement communication, relevant wage computation and payment particulars. A nominee/heir application additionally needs the genuine nomination/death/succession evidence applicable to that route.

Worked calculation: ₹52,000 × 15 ÷ 26 × 10 = ₹3,00,000. No rounding or extra part-year is assumed.

Official source and version

Official Gazette, Social Security (Central) Rules, 2026; Form IV; PDF pages 211–212

Download the official source pages containing this form. Adjacent prescribed forms can share a source page; use the heading and rule identified above.

The Central Rules have their stated jurisdiction. The corresponding appropriate-government rules and any later amendment must match the real establishment and event.

Practical questions

Can I submit the sample as my own completed form?

No. Replace the fictional facts with accurate records, use the competent filing or record-keeping route described above and complete genuine signatures or certifications where required.

What makes the example specific to this form?

This is the prescribed employee gratuity claim under (See rule 33(1), with its own parties, event, required entries and legal function.