Leave Travel Allowance (LTA) DECLARATION – Financial Year -

Self Declaration by Employee

I …………………………………………………. (Name of the employee), with employee id…..……….do hereby confirm

that:
I am claiming expenses incurred for Economy Class Fare only. (Applicable if travelled in Air ways).
I have travelled by the shortest route.
Start point (Place From) End point (Place To) Mode of Travel Total Fare Rs.
     
(Please refer the illustrations provided in the policy FAQs)

Following are the details of my approved leave:

Start Date End Date
Leave Period
   

Below are family member’s details accompanied in my travel (Name and Relationship)
Family member name Relationship Family member name Relationship
1.   6.  
2. 7.
3. 8.
4. 9.
5. 10.

Further, I am aware that

i) Journey through sea, hired taxis, mini-buses and personal cars cannot be claimed. Expenses
incurred towards hotel charges (food, accommodation) toll charges, driver's bata local conveyance
like taxi charges from residence to the airport are not be reimbursable.
ii) In case of multiple destinations, the claim will be reimbursed to the extent of 1 st a/c train fare by
the shortest route from the start point to end point.
iii) Travel should be a round trip and the start location should be my work location.
iv) Exemption will be allowed on travel expenditure of self, parents, spouse, children (max 2) & fully
dependent siblings.
I confirm,
i) that the exemption under section 10(5) of the Income-tax Act, 1961 (the Act) claimed by me is in
accordance with the sub-rule (2) of Rule 2B of the Income-tax Rules, 1962 (the Rules) as per which
the exemption can be claimed only for two journeys in a block of four calendar years
commencing from 1986.
ii) that I shall be fully responsible to the Company for any income-tax liability including interest,
penalty etc. that may arise on account of non-fulfillment of this undertaking in-toto or in part by
me.

Date:

Place: (Signature of Employee)

Claim No.