The full text of this document as VidhiSar drafts it, with every blank shown in square brackets. Copy it or download it as a Word file and fill it in yourself — or answer a few questions and VidhiSar fills it in and prints a formatted PDF. Clauses that apply only in some cases are left out here; the drafting flow adds them when your answers call for them.
STATEMENT DETAILS
Date: [Statement Date]
Employee: [Employee's Full Name]
Employee Code: [Employee Code / ID]
Designation: [Designation at Separation]
Date of Joining: [Date of Joining]
Last Working Date: [Last Working Date]
Issued by: [Company Legal Name]
Subject: Statement of Full and Final Settlement of Account
EARNINGS
1. Unpaid Salary. Salary for [Unpaid Days Worked in Final Month] day(s) worked in the final month and not yet disbursed: Rs. [Unpaid Salary].
2. Leave Encashment. Encashment of [Leave Days Being Encashed] day(s) of accumulated leave standing to the employee's credit as at the last working date: Rs. [Leave Encashment].
3. Gratuity. Gratuity payable under section 53 of the Code on Social Security, 2020, computed at fifteen days' wages on last drawn wages for each completed year of continuous service and part thereof in excess of six months: Rs. [Gratuity Payable]. Where the employee has not completed the qualifying period of continuous service, this amount is recorded as Nil.
4. Bonus, Incentive and Reimbursements. Statutory bonus, performance incentive and approved expense reimbursements outstanding as at the last working date: Rs. [Bonus / Incentive / Reimbursements].
DEDUCTIONS
5. Notice Period Recovery. Recovery in respect of the unserved portion of the notice period, as provided in the employee's contract of employment: Rs. [Notice Period Recovery].
6. Other Recoveries. Advances, loans, asset non-return charges and other amounts lawfully recoverable: Rs. [Other Recoveries].
7. Tax Deducted at Source. Tax deducted at source under the Income-tax Act, 2025 on the taxable component of this settlement: Rs. [Tax Deducted at Source].
NET SETTLEMENT
8. Net Amount Payable. The net amount payable to the employee on full and final settlement is Rs. [Net Amount Payable], to be remitted by [Payment Mode] on or before [Payment Date]. The wages included in it fall due within two working days of the last working date under section 17(2) of the Code on Wages, 2019, and gratuity within thirty days of it becoming payable under section 56 of the Code on Social Security, 2020.
9. Statutory Fund Balances. Balances standing to the employee's credit in the provident fund and any other statutory fund are held by the respective statutory authority and are not part of this settlement. They are to be withdrawn or transferred by the employee directly with that authority, and the Company shall complete its part of the formalities on request.
10. Certificate of Tax Deducted. A certificate of tax deducted at source in the prescribed form shall be issued to the employee for the relevant tax year within the timeline prescribed under the Income-tax Act, 2025 and the rules made under it.
11. Basis of Statement. This statement has been prepared on the records available to the Company as at the date of issue. Any arithmetical error or omission notified by the employee in writing within thirty (30) days shall be examined and, if established, corrected and settled.
ACKNOWLEDGEMENT
For [Company Legal Name]
[Authorised Signatory Name]
Authorised Signatory
Received the sum stated at Clause 8 in full and final settlement of all my claims arising out of my employment with the Company, subject to Clause 11 above.