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……………………………………..

SI. 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