Annexure A

Cost To Company

Employee CodeNameDesignationBand and GradeDOJDepartmentLocation/BranchDate Of BirthFather NameFather’s NameBenefits (A) Monthly YearlyBasicHRACommutation & Conveyance AllowanceMedical AllowanceOther AllowanceTotal A Reimbursements (B)Petrol and car MaintenanceDriver’s SalaryEntertainment AllowanceSudexho Meal CouponsMedical ReimbursementTotal BContributions (C)Contribution to Gratuity (paid by emplr)Contribution to PFTotal CTotal (A+B+C)

In Words- Rs. dddddddd only

Note: Any tax liabilities arising out of the remuneration will be deducted as per the Income Tax rules.

Mr. ABCManager- Human Resources