LTA – Expenses Statement

NAME:

EIN:

I ___________________________________hereby declare that I have incurred the following

expenses while I was travelling during my period of leave. I am aware of the provisions of the
Income Tax Act, 1961 and the rules made there under pertaining to Leave Travel Allowance.
I was on leave during the period from _____________ to _____________ and travelled from
______________________ (Source) to _____________ (destination).

My Leave Travel Allowance is to be exempted from tax up to Rs.______________________ (Claim

Amount)

Members of my family travelling with me are

Sl
No Name Relationship Age

Details of Travelling Expenses:

Amount
Sl Mode of Amount Eligible &
No Travelling From Travelling To Transport Spent (Rs) Claimed

Grand Total

I hereby declare that everything stated above is true to my knowledge and I would be responsible
for compliance with the IT Act 1961 in this regard.

Signature of the Employee: ___________________

Date: ___________