Company Name Statement for Full & Final Settlement Employee Details : Code Name Designation Dept.

Date of Joining Basic Salary : : : : : : ******* ***************** *************** ************ ************** ************

Location Property NO Dues Date of Leaving

: : : :

*********** ********** ******** **********

Payment to be made : 1. Salary 2. Conv. Reimbursement 3. P.L. Encashment 4. Med. Reimburesment 5. L.T.A. 6. Gratuity 7. Bonus / Ex-Gratia 8. Other Earning

( ( ( (

******** 0 0 0 0

) ) ) )

to ********** Days Days Days Days

(** LWP)

Total Earnings Dedutions : 1. P.F. 2. Professional Tax 3. E.S.I. 4. LWF 5. Income Tax / TDS 6. Advance / Loan 7. Other Deductions 8. Notice Period

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 --------------------0.00 ---------------------

10.04

) Days Total Deductions Net Payable Amount in Rs. Round Up Amount Net Amount

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 --------------------0.00 --------------------0.00 --------------------0.00 0.00

Prepared By

Checked By

Authorised By

DECLARATION RECEIVED Rs. ONE THOUSAND FOUR HUNDRED SEVENTEEN ONLY TOWARDS FULL & FINAL SETTLEMENT OF ALL MY DUE FROM Company Name VIDE CHEQUE NO. DATE : DRAWN ON I ALSO CERTIFY THAT THIS SETTLEMENT IS MADE SUBSEQUENT TO MY RESIGNATION AND IS ACCEPTED BY ME IN FULLEST SATISFACTION. I HAVE NO MORE CLAIMS TO BE MADE FROM

Company Name
Accepted by