Company name NO DUES CERTIFICATE PART “A”

Mr./ Ms. ___________________________ EMP No_______ Designation :-______________

Department:- _______________ has resigned from service of company and he /she will be
relived from the services of company with effect from ____________. (after closing hours).
Please indicate dues, if any in his / her name from your department to enable us to settle
his /her final dues.

Date : MANAGER HR & IR

Department Dues if any(in Rs) Signature of HOD
Concerned HOD
General stores
Accounts
Security
Safety/Environment
Personnel & Admin
(Canteen/I.-card/Housing)
Society-Emp.
Co-op. credit
Technical library

TIME OFFICE/PAYROLL PART “B”

1 LTA payable / recovery Rs
2 Medical reimbursement payable Rs
3 No. of days payable during current month ___________days
4 No. of days payable for last month _________ days
5 Leave encashment(days) ___________days

TIME - OFFICE

HR SECTION PART “C”

1 Gratuity payable, if any
Date of Joining: ____________ Yes/No
Dt of Leaving: _____________
____years____months__days

Claim form in respect of Gratuity –Form “I” Received / Not received

2 Notice pay Recovery , if any _______days

3 Other deductions, if any

MANAGER – HR & IR

CONTD..2
 NO DUES CERTIFICATE / PAGE:2
PART “D”
(To be filled by an employee seeking separation or being relieved from the services of
Company)
I wish that following action is to be taken in respect of my-

S No. Heads Details

1 PF/FPF
2 Gratuity
3 Bonus
4 Superannuation
5 Address for
correspondence

6 Address for remittance of

dues, if any

I agree to reimburse or repay the total amount against my personal bills, if any the Company
may receive that after I am relieved from the services of Company.

Date :
Place : SIGNATURE
RECEIPT
RECEIVED a sum of Rs …………………….(Rupees ……………..) from the Management
of M/s ________________ Limited, Address- ________________ in full and final
settlement/satisfaction of all my claims/demand for reinstatement or reemployment including
earned wages, encashment of leave, notice pay, retrenchment compensation, bonus
Gratuity and all other dues which could accrue during the employment with the company. I
HEREBY DECLARE THAT I DO NOT HAVE ANY CLAIM WHATSOEVER AGAINST
M/s INA Bearings Private Limited

I SAY RECEIVED Rs……………… vide cheque No……………dated………………

Drawn on Bank of ………………………..

FULL NAME : SIGNATURE

Date
[ pl affix revenue stamp of Rs1/-]