Exit No Dues Clearance Form

Employment Details - Completed by employee

Employee Name Title. First Name + Middle Name + Surname
Employee Code Designation
Employment Type Cost Centre
Reporting Manager Name Department
Subsidiary Name Location
Termination Date Last working Date
Contact Details - For Future correspondence
Contact Number 1 Contact Number 2
Personal Email ID
Residential Address Permanent address

Pincode State Country Pincode State Country

Assets Handover - Completed by related departmental authorities with signatures

Department Inventory Status Comments Hand over taken by
Files/ Manuals/Handbooks Yes/No/NA
Own Other Documents Yes/No/NA Name & Signature
Any other (specify below) Yes/No/NA

Email ID & User ID Deactivation Yes/No/NA

Information Desktop / Laptop Yes/No/NA
Technology Data Modems Yes/No/NA Name & Signature
(IT) Data back-up tools Yes/No/NA
Any other (specify below) Yes/No/NA

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 Exit No Dues Clearance Form

Mobile Handset & Sim Card Yes/No/NA

Stationary Yes/No/NA
Cabinet & Drawer Keys Yes/No/NA
Admin Name & Signature
Travel Advance Yes/No/NA
Parking Bay Yes/No/NA
Any other (specify below) Yes/No/NA

Imprest Account (Specified

Yes/No/NA
losses)
Human Company Leased Accommodation Yes/No/NA
Capital Name & Signature
Employee ID Card/Punching Card Yes/No/NA
(HC)
Visiting Cards Yes/No/NA
Any other (specify below) Yes/No/NA

Checklist – Completed by HC Team

Topics Status Date
Exit notice received (Resign/termination/retirement letter copy) Yes / No / NA DD / MM / YY
PF withdrawal form sent to employee Yes / No / NA DD / MM / YY
Personnel manual Yes / No / NA DD / MM / YY
Exit interview conducted with exit form Yes / No / NA DD / MM / YY
IT Ticket logged by Yes / No / NA DD / MM / YY

Payroll Clearance – Completed By Payroll Team

Components Status Details Amount Data furnished by
Dues on account of salary Yes / No / NA
Any other discretionary remuneration Yes / No / NA Payroll Administrator
No. of paid leave to be en-cashed Yes / No / NA
Name & Signature
Other Yes / No / NA
Other Yes / No / NA
Deductions
Salary in advance Yes / No / NA
Notice pay buy out Yes / No / NA
No of days of notice period to be recovered Yes / No / NA
Telephone / mobile bill/cost deduction Yes / No / NA
Retention bonus
Employee Loan Yes / No / NA
Study Loan /Agreement Yes / No / NA
Other outstanding fees Yes / No / NA
Bonds / undertakings Yes / No / NA
Salary paid up to (date): Yes / No / NA

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 Exit No Dues Clearance Form

For Employee -
Name Signature Date DD / MM/ YY

Comments By HOD
Functional Head

Name Signature Date DD / MM/ YY

Human Capital Manager

Name Signature Date DD / MM/ YY

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