PERFORMA PPO NO.

APPLICATION FORM FOR THE SANCTION OF ONE MONTH PAY IN LIEU OF LEAVE TRAVELLING
CONCESSION DURING THE CURRENT FOUR YEARS BLOCK 2020-2023 AS PER GOVT. OF
HARYANA, INSTRUCTION NO. 5/17/2009-4FR DATED 11-04-2012.

1. Name of Applicant :
(In Block Letters)
2. Designation :
3. PPO NO :
4. Date of Birth :

5. Name of Office from where retired :

6. Existing (Revised) Basic Pension (as on
The date of application) :
7. Whether L.T.C. drawn in the
Current Block of four years
(2020-2023) has earlier availed by
The applicant or not :
8. Whether Wife/Husband is employee
Of Hr. Govt. Board/Corp. or local
Bodies if so give detail thereof
Undertaking be attached :

Certified that the above statement is true to the best of knowledge and belief.

Place: (Signature of Applicant)

Date:

Only for retiree after 01.01.2020:-

Certified that ………………………… S/o Sh………………………….. retd on. ……………,
PPO NO……………have not paid LTC for the Block year 2020-23.

Singanature of DDO with seal.

 Undertaking
Under para 1 (iii) of instruction in memo no. 13/19/2008-2SII dated 18.05.2009, it is hereby undertaken
that:

1. I am eligible to draw the benefit promised by the scheme put in place vide memo no.
13/19/2008-2SII dated 18.05.2009.
2. None amongst my entitled family members, including the spouse, is either in service of
Government of Haryana or in service under Central Government or any other
organization/institution/body etc. wholly or substantially owned or controlled by the Central
Government or any State Government.

Under Para 1 (iii) of instruction in memo no. 13/19/2008-2SII dated 18.052009, it is hereby undertaken
that:

1. I am eligible to draw the benefit promised by the scheme put in place vide memo no.
13/19/2008-2SII dated 18.05.2009.
2. My entitled family members, including the spouse, who is in the employment of government of
Haryana, and who is also eligible to draw the benefit promised by the scheme put in place vide
memo no. 13/19/2008-2SII dated 18.05.2009 shall not avail the benefit promised by the scheme
put in place vide memo no. 13/19/2008-2SII dated 18.05.2009 separately for the current block
of four years regulating the LTC.
Or
My entitled family members, including the spouse, who is in the employment under the Central
Government or any other same Govt. or under any other organization/institution/body, etc.
wholly or substantially owned or controlled by the Central Government or any State
Government shall not avail of the facilities of LTC from their employee in whatever form it is
extended to him/her by their such respective employer.

Name/designation/signature of the concerned employee