: FORMAT Finance Department ITC Infotech India Limited Bangalore ‘The undersigned indemnifies and agrees to keep ITC Infotech India Limited indemnified against all and any costs, losses, damages, expenses (including all legal expenses on a full indemnity basis) or other liability sustained or incurred by ITC Infotech India Limited as a result of ITC Infotech India Limited settling my claim bearing serial No. dated.............based_on duplicate document(s)/ bill(s/ photocopy of document(s)! bill(s) attached therewith The undersigned hereby declares that the original document(s)/ bill(s) have been lost and the same are not traceable. The undersigned agrees and undertakes (o retum the original document(s)/ bill(s). in case it is located at a later date to Finance Department immediately after marking the Claim ID Number and date, ‘The undersigned further agrees and undertakes to refund the entire amount received in settlement of the claim as mentioned above to ITC Infotech India Limited in case the same is found to be claimed at any time on submission of the original document(s)/ Dill(s). ‘+ List of supporting documents lost: 3. Name of Employee: Signature: Employee No: Date: HOD’s Endorsement : Signature: Date — Los”