( COMPANY NAME )

LEAVE TRAVEL ASSISTANCE FOR THE YEAR ……………………..

(To be filled after the travel)
(Ensure that no column is left blank. Incomplete Form will not be entertained) (Expenses incurred
on using own vehicle during travel will not be considered for reimbursement)

NAME : DESIGNATION: BRANCH:

EMPLOYEE CODE: FUNCTIONAL AREA: DEPARTMENT:

ZONE: DATE OF THIS APPLICATION: BASE STATION:

LEAVE PERIOD DETAILS

PRIVILEDGE LEAVES AVAILED FROM _ _ _ _ _ _ _ / _ _ _ _ _ _ _ / _ _ _ _ _ _ _ TO _ _ _ _ _ _ _ /_ _ _ _ _ _ _ / _ _ _ _ _ _

DETAILS OF PERSONS TRAVELLED

NAME OF THE PERSON
GENDER AGE
S.NO (LTA claims can be made only for RELATIOSHIP WITH EMPLOYEE
(Male / Female) (Years)
Self, Spouse, Children, Dependent Parents only.)

1 Self

TRAVEL EXPENSE DETAILS

BILL NO. / CASH MODE OF
S.NO TRAVEL ORIGIN PLACE DATE TRAVEL DESTINATION PLACE AMOUNT
MEMO NO. TRAVEL

1 RESIDENCE
AIRPORT / RAILWAY STATION / BUS
STATION

I HEREBY DECLARE THAT THE ABOVE GIVEN INFORMATION IS CORRECT

SIGNATURE OF EMPLOYEE
 HR RECORDS & ACTION
PAID WITH SALARY FOR THE MONTH _ _ _ _ _ _ _ _ _
LTA AMOUNT BROUGHT FORWARD FROM THE FIN YEAR (_ _ _ _ _ _ _):

PAID THROUGH CHEQUE DATED _ _ _ _ _ _ _ _.

LTA AMOUNT ENTITLED FOR THE CURRENT FIN YEAR (_ _ _ _ _ _ _):

LTA AMOUNT PASSED AS PER ENTITLEMENT FOR: Rs. ………………… /-

SIGN: DATE:
AUTHORIZED BY HR