Employees’ Dues particulars to be included in Full & Final Settlement.

(For Payroll Department)

 TO BE FILLED BY THE EMPLOYEE

I Mr. __________________________________________ (Emp. No. ___________,

Location_______________ ) have resigned from the services of the company as on date
_________________ and being relieved from the Company w.e.f. dated _____________. I have no
claims of what so ever nature which includes re-instatement and re-employment also on the management
as described

Pending dues to be included in my final settlement are as under: -

1) Salary for the month of _____________ for _____days not received earlier.

2) Travel Expenses statement for the period _________ to ________ for Rs. _________ for which travel
expense statement enclosed herewith duly authorized by Department Manager or HOD.

3) Advance / Loan with me Rs. _____________ to be deducted from my final settlement dues.

4) Other dues to be taken into account not specified in the list given above: ( Kindly give details of the
same)

5) Specify if authorized signatory of any company matter/ document Yes/ No ____________ Signature
by HOD ____________

Signature by HOD ____________

Signature of employee
Name: Name of Dept. Manager _________________

Address: Authorized by Dept. Manager ____________

Authorized by HOD: ___________________

 (To be retained by Accounts Department)

SETTLEMENT CLEARANCE ( to be filled by the Dept. Manager)

Name of the employee: Employee Code:

Department: Designation:

Date of joining: Resigned on:

Salary for the month of ________________ not received earlier

Company’s’ Documents Nos. Signature of a person

to whom charge given
1)
2)
3)
4)
5)

Company’s Property Possession Person’s signature to

whom handed over (If yes, please give details)
1) House accommodation Yes/No
2) Vehicle Yes/No
3) Telephone Yes/No
4) Equipments Yes/No
5) Others Yes/No
6) Files pass words Yes/No
Advance Status:
1) Vehicle Loan Yes/No
2) Housing Loan Yes/No
3) Housing Loan Yes/No
4) Personal Loan Yes/No
5) Salary Advance Yes/No
6) Exp. Advance Yes/No

Any advance taken from a place other than employees’ location of work. Please give details:
Amount taken Rs. from: Dt:

Purpose of said advance

Earlier Leave Encashment Status
Gratuity Receipt from Earlier Employer
PF / FPF Status:

Wish to withdraw Yes/No

Desired to transfer Yes/No

( Please fill form 13 for PF transfer, form 19 for PF withdrawal & form 10 C for FPF withdrawal)
Correspondence address and telephone no ( if any)
For remittance to be sent

Date:
Place:

___________________________ _______________ ____________________

Department Manager Signature HOD Employee’s Signature
 SETTLEMENT CLEARANCE FORM

Name:
Emp. No.:
Department:
Relieving Date:

Please let us know if there is any material/amount due from him/her.

S.No. Department Particulars Signature

1 Accounts

2 HRD

3 IT

4 Administration

Car

Laptop

Any other

5 Personnel

6 Marketing

7 Legal

10

Personnel Department
Date: