Company Name

Full & Final Settlement Statement Date of Joining:

Name: Date of Leaving:
Designation: Years of Service: 0.00

EARNINGS: Days Amount (Rs.)

Salary for the month of__________ 0.00
Travel Advance reimbursement 0.00
PL Encashment 0.00
Leave Travel Allowance 0.00
Notice period 0.00
Medical Expenses 0.00

TOTAL EARNINGS (A) 0.00

DEDUCTIONS:
Provident Fund 0.00
ESIC 0.00
Travel Imprest 0.00
Travel Expenses Disallowed by company 0.00
Loans / Advances recovery 0.00
Prorata Premium on Mediclaim Policy 0.00
Recovery excess claim in Medical Expenses 0.00
Recovery excess claim in LTA 0.00
Recovery of Company belongings 0.00
Recovery due to short-fall in notice period 0.00
Income Tax Recovery 0.00
TOTAL DEDUCTIONS (B) 0.00

NET AMOUNT TO BE PAID / (RECOVERED) (A-B) 0

____________ ____________ _____________ _____________ ____________

HR officer O & M Head HR Head Head Finance MD

I confirm that the above is the correct statement of my full and final settlement
in respect of my services with the company and that on payment of
Rs.
Company has to pay me.
There will be no amount due from the company to me. Signature