Leave Travel Allowance Claim Form

Name: Employee No:

Designation: Department:

Details of Person Travelled:

Sl No. Name of the person Relationship to the Employee

1
2
3
4
5

Journey Details:

Sl. Date of From To Mode of Ticket or PNR Amount in

No. Travel Travel No. INR
1
2
3
4
5
6
7

Total Amount Claimed:

Declaration:

I, , hereby declare that I have actually spent the claimed amount for travel on leave by self and
family. I have submitted my LTA claim for the claim of my current block of LTA year 2022-2025.

Date:

………………………………………….

Signature of the Employee