FORM E
Application for withdrawal
[See Paragraph 10(1)]

State Bank of India, Branch .
Site Restoration Fund Scheme, 1999
Branch
Deposit Account No.
Name of depositor :
Please pay a sum of Rupees (in figures) (Rupees ) (in words) from out of the balance in the above deposit account by way of credit to the designated account standing in my/our name being Account No. in State Bank of India Branch for the purpose of meeting expenditure mentioned in paragraph 9 of the Site Restoration Fund Scheme, 1999.
Signature of depositor
I hereby authorise the above withdrawal for the purpose of utilisation in accordance with paragraph 9 of the Site Restoration Fund Scheme, 1999.
Signature of the authorised officer of the
Ministry of Petroleum and Natural Gas or the
agency authorised by the Ministry of Petroleum
Date : . and Natural Gas in this behalf.
Place : .
(FOR BANK USE ONLY)
Amount paid by credit to the designated A/c. No. with through
MT/TT.
Date : .
Seal of the bank ..
Signature of Officer-in-Charge