FORM F
Application for closure of account
[See Paragraph 12(2)]

State Bank of India, Branch
Site Restoration Fund Scheme, 1999
Branch
Deposit Account No.
I/We (name and address of the depositor) wish to close Deposit Account No. in terms of paragraph 12 of the Site Restoration Fund Scheme, 1999, and consequently, withdraw the balance to the credit of the account in accordance with the said paragraph 12.
The balance payable should be transferred to our designated Account No. with the State Bank of India, Branch.
The certificate of the Ministry of Petroleum and Natural Gas/agency authorised by the Ministry of Petroleum and Natural Gas in this behalf, specified in paragraph 12 of the Scheme is enclosed.
The certificate of the Assessing Officer specified in paragraph 12(2) of the Scheme is enclosed.
Date :
Place :
Signature of depositor
(FOR BANK USE ONLY)
Balance Rs. credited to the designated Account No. with through MT/TT.
Date : .
Seal of the bank
Signature of Officer-in-Charge