Claim for Leave Travel Allowance

4 Yrs LTA Block

For the period …26-Dec-2022… to …30-Dec-2022.… 2022 – 2025

1. Name of Employee ……………Tarun Jain………………………………Emp_Code. .……01010683.

2. Department …FBIS…………………………. Designation …………ICB Expert……………...……………..

Please mention LTA availed in
3. Period of Journey from ……26-Dec-2022………………. to ….30-Dec-2022…. Total....5 Days the current block either as Non Taxable or Taxable
Tick the BOX
4. Place/Places Visited ………………Dibrugarh………………………………………...………………...

5. Travel Started from ………Delhi……………………….. to ………………… Dibrugarh ………………

Non Taxable Taxable
6. Leave availed (Approved by HR) from …………26-Dec-2022….. to …………30-Dec-2022……..
2022 :- Y
7. Amount of L.T.A. Entitlement / Claim Rs…………………78772.54.........………….……………

8. Mode of Transport with supporting (Air/Train/Taxi) : …………Air……………………. 2023 :-

9. No of Family Members Travelled & Relations
2024 :-
Sr. No Name Relation Age
1 Tarun Jain Self 35 2025 :-
2 Sonam Jain Wife 33
3 Ayansh Jain Son 3
4 Shyam Lal Jain Father 69 As per LTA rules in a Block of 4 years.
5 Kusum Jain Mother 65
2 Yrs Non Taxable and 2 Yrs Taxable ha

It is verified that I have actually spent the above amount on journey with my family members.

(Signature of Employee) Date: ……12-03-2023……………

 Yearly Monthly Claim-As-You-Earn for
Sl
Descriptions Maximum Maximum FBP Reimbursement Document to be submitted
No.
Entitlement Entitlement Components
Only DOMESTICS Travel
allowed
Airways :- Airway ticket
along with boarding passes
are must to claim LTA
reimbursement.
Railways :- A Travelling
ticket which is purchased
through a railway ticketing
counter or a Eticket which is
booked through internet is
required for LTA
reimbursement.
Grade
Note :- Please attach any
Based,
LTA is an exception Hotel/restaurant/toll bill to
which can be paid to an support your travelling to
Leave Travel Minimum 2
1 0 to 250000 employee in advance the destination you have
Assistance days Annual
for entitlement upto travelled..
leave to
Financial Year end.
avail LTA
reimb. Roadways :- Any hired
Car/Taxi bill with clearly
mentioning the date of
Travel, Travelled from and
to place, KM's travelled.
Note :- Please attach any
Hotel/restaurant/toll bill to
support your travelling to
the destination you have
travelled..
Rules-1 Rules-2
Clarification regarding LTA combined
travelling:-
IF Taxi bill are submitted along with
Air/Rail tickets certain points has to be
remembered,
> Only “source to destination” and back
will be allowed.
> Local travelling, sightseeing, fooding,
lodging are NOT allowed.
> No Multi travelling are allowed for
example (travelled to hometown ie
Bangalore to Delhi and then travelling
from Delhi to Jammu and back to Delhi,
and again travelling from Delhi to Shimla
and back to Delhi..
> Only one trip is allowed to the last
destination ie Bangalore to
A/C First class
Jammu/Shimla and back to Bangalore
fare to be
with break-journey in it..
calculated
> No pick-up and drop taxi bill are
based on the
allowed ie (home to railway
KM's
station/airport and vice-sa-versa)
travelled, no
> To support your travelling any
Flat amount
Hotel/Restaurant/toll bill has to be
will be
submitted along with the taxi bill
approved.
submitted.