LTA – Expenditures Statement

ENEmplyee:

ID:

I ___________________________________hereby announce that I have experienced the

succeeding expenses while I was travelling during my period of vacation. I am aware of the
provisions of the Income Tax Act, 1961 and the rules made there under concerning 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: ___________