[Company Logo][Company Name]
- Ref. No.:
- [Reference Number]
- Date:
- [Date]
- Loss / Damage Report Ref.:
- [Report Number]
1. Employee Details
| Employee Name | [Employee Name] |
|---|
| Employee ID | [Employee ID] |
|---|
| Designation | [Designation] |
|---|
| Department | [Department] |
|---|
| Monthly Gross Salary: ₹[Amount] | |
|---|
| Employment status: Active / Serving notice / Exited | |
|---|
2. Asset Details
| Asset ID | Description / Make / Model | Serial No. | Purchase Date | Purchase Cost (₹) | Loss / Damage Date |
|---|
| [Asset ID] | [Make / Model] | [Serial Number] | [DD/MM/YYYY] | [Amount] | [DD/MM/YYYY] |
3. Valuation
| Item | Amount (₹) |
|---|
| Value as per policy (basis: depreciated value / replacement cost / policy rate) | [Amount] |
| Less: Insurance claim received / expected | [Amount] |
| Less: Warranty / salvage value | [Amount] |
| Net loss to company | [Amount] |
| Employee share as per policy ([Percentage]%) | [Amount] |
| Amount waived by management | [Amount] |
| Final amount to be recovered | [Amount] |
4. Basis of Decision
[Summarise the findings of the review, the employee's explanation and the clause of the asset policy relied upon.]
5. Recovery Schedule
| Instalment | Month | Amount (₹) | Mode |
|---|
| 1 | [Month Year] | [Amount] | Salary / F&F / Direct payment |
| 2 | [Month Year] | [Amount] | Salary / F&F / Direct payment |
| 3 | [Month Year] | [Amount] | Salary / F&F / Direct payment |
6. Employee Response and Consent
| Employee comments | [Comments] |
|---|
| I agree / do not agree with the recovery stated above | |
|---|
I, [Employee Name], have been informed of the findings and the basis of the amount above and was given an opportunity to explain. I consent to the recovery of ₹[Amount] in the manner set out in the recovery schedule.
Employee
[Employee Name]Date:
[Date]Finance / Payroll
[Finance Executive]Date:
[Date]Approved by
[Authorised Signatory][Designation]Date:
[Date]