FORM D
Statement of account
[See paragraph 4(5)]

State Bank of India, Branch .
Site Restoration Fund Scheme, 1999

Branch
Name of Depositor
Address of depositor
Permanent Account Number
Deposit Account No.
Period from to .
Sl. No. Date Cheque/DD/
Bank transfer/
interest
Particulars Credit (Rs.) Debit (Rs.) Balance (Rs.)
Opening balance
Closing balance
Date : .
Place : .
Signature of Officer-in-Charge