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
and Natural Gas in this behalf.
Date : ………….                                                     
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