Swal Corporation Ltd

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 _____________.

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

4) Leave encashment for the _______ days credit to my account.

5) Gratuity Payment ( ______Yrs ________Month ______Days of service )

6) Leave Travel Concession from _________ to __________ for Rs. ___________ due to me not
claimed earlier ( Taxable / Non taxable )

7) Medical Reimbursement from ________ to ________ for Rs. ________________

( Medical Bills to be attached with the medical format)

8) Incentive Rs. _______________ eligible and payable for target achieved for the period ____________
HOD approved letter enclosed.

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

10) Notice Pay Payment / Recovery _______ days / month.

11) Specify if authorized signatory of any company matter/ document Yes/ No ____________ Signature
by HOD ____________
12) Action taken by company on point no.11 to delete the same. Signature by HOD ____________

Signature of employee
Name: Name of Dept. Manager _________________

Address: Authorized by Dept. Manager ____________

Authorized by HOD: ___________________

 Swal Corporation Ltd
( To be retained by HRD 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

Companys Documents Nos. Signature of a person

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

Companys Property Possession Persons 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) Imprest Yes/No
2) Vehicle Loan Yes/No
3) Housing Loan Yes/No
4) Housing HDFC Loan Yes/No
5) Personal Loan Yes/No
6) Salary Advance Yes/No
7) 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 Employees Signature
 Swal Corporation Ltd
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: