Annexure “B”

Certificates to be given by a Government Employee

1. I have not submitted any claim so far leave travel concession in respect of myself or my
family members in respect of the Block years from 2018 to 2021.

2. I have already drawn T.A. for the LTC in respect of a journey performed by me/my
wife with ___________ children. This claim is in respect of the journey performed by
my wife/myself with ____________ children none of whom travelled with the party on
the earlier occasion.

3. I have not already drawn T.A. for the LTC in respect of a journey performed by me/my,
wife with ___________ children in respect of the block of two years/four years from
2018-21. This claim is in respect of the journey performed by my wife/myself with
__________ Children none of whom availed of the concession relating to that block.

4. I have already drawn T.A. for the LTC in respect of a journey performed by me in the
years ____________ in respect of journey perform by me in the years _____________
in respect of the block of two years/four years from ____________ and ____________.
This claim is in respect of the journey by me in the year ______________. This is
against the concession admissible once every two years in a prescribed block for
visiting home town as all members of my family are living away from my place of
work.

5. The journey has been performed by me/my wife with ___________ children. To declare
home town viz./place _____________________ in India.

6. That my husband/wife is not employed/that my husband/wife is employed in

Government service and concession has not been availed of by him/her separately for
himself/herself or any of the family members for the concerned block of two years/four
years.
 Annexure “C”
UNDERTAKING
I, __________________________________ son/daughter of Shri ______________________

employed as _____________________ in the office of _____________________________,

do hereby solemnly affirm and declare that the journey in respect of which LTC for visiting

____________ to ____________ my Bill for the period from ____________ to ____________

were actually performed by me and the members of my family as per details in the LTC Bill.

PLACE:
DATE: DEPONENT

VERIFICATION

Verified that the above facts are true to the best of my knowledge and belief that nothing
relevant has been concealed therein.

PLACE:
DATE: DEPONENT
To,
The Sr. Executive Engineer,
CC Division, BBMB,
Nangal Township.

Subject: Request for leave encashment.

Respected Sir,

Please allow to me Leave encashment against 10 days earned leave to availing

the LTC for the block year 2018-21.

Thanking You.

Yours Faithfully,