EMPLOYEES' STATE INSURANCE CORPORATION

SRO - Alkapuri Baroda

LTC Settlement (Home Town/ All India) Application

Bill No. :
Request No. : LTC0000035833
Date :
Employee Details

Employee No./ Employee Name 172689 - SARJEET Marital Status : Married

Designation : Assistant Service Period left over (In years) : 28
DOJ Government Service : 22/01/2018 Physically Challenged : No
Branch/ Divsion : F&A / F&A Family Residing at : Present
Is Suspended : No

Employee Pay Details

Pay Level : 6
Basic Pay : 37600

Employee Address
Present : Home Town :
F503 FORTUNE GLORY VADSAR VISWAHMITRI ROAD NEAR OM VPO DHABI KALAN DIST TEH FATEHABAD FATEHABAD HARYANA
SCHOOL VADODARA GUJARAT 390012 125053

LTC details :

LTC Journey for : HomeTown HomeTown Converted Y

Declared Place of visit : Neil Island Saheed dweep LTC requested for : Self & Family
Proposed Date of commencement 25/11/2023 Trip Undertaken : Yes
LTC Block Year: 2022-2025

Family Details

Sl No. Name Age Relationship Gender Govt Employee Is Dependant

1 kamlesh 34 Spouse female No Yes

2 ANANTA 2 Daughter female No Yes

Escort

Sl No. Name Age

1 NA 0

Travel Settlement Details

Sl No. Journey From Journey To Travel Date Mode Of Travel Class/ Coach Ticket No. Actual Amount Sanction Amount
1 vadodara ahmedabad 25/11/2023 Road Bus 00001909 264.00

2 ahmedabad port blair 26/11/2023 Flight Economy S65VNR 42516.00

3 port blair havelock swraj 27/11/2023 Ship Economy XYZUKV 3300.00

dweep
4 havelock swraj neil island saheed 29/11/2023 Ship Economy PAAWEO 2900.00
dweep dweep
5 neil island saheed port blair 30/11/2023 Ship Economy 61E155B6 3300.00
dweep
6 port blair ahmedabad 30/11/2023 Flight Economy B3PPFB 47193.00

7 ahmedabad vadodara 30/11/2023 Road Bus TICKET LOST 0.00

Local Conveyance Details

Sl No. From To Date Mode Of Travel No. of Km Rate per km Claimed amount Actual Amount Sanction
1 NA NA NA NA 0.00 0.00 0.00 0.00

Miscellaneous Details

Sl No. Expense Type Amount Sanction Amount

1 NA 0.00

Challan Details

Sl No. Challan Number Challan Date Realized Date Amount

1 NA NA NA 0.00

Amount of Advance Applied

Amount Sanctioned (A) : 81761.00

Settlement Amount (B) : 99473.00

Refund by employee to ESIC (C = A - B) : 0.00

Net payable by ESIC (D = B - A) : 17712.00

Notings : PL APP ALL BOARDING PASS ATTACHED IN HARD COPY

 L.T.C. CERTIFICATE
CERTIFICATE TO BE GIVEN BY THE CONTROLLING OFFICER

(i)Certified that Sh./Smt./Ms. ................................................................................................................ ( Name of the Govt. servant has rendered continous service for

one year or more on the date of commencing the outward journey.

(ii)Certified that necessary entries as required under Para 3 of the Ministry of Home Affairs O.M. No. 43/1/55-Ests.(A) part II. dated 11th October. 1956 have been

Counter Signed :

Signature of Controlling Authority :

CERTIFICATE TO BE GIVEN BY THE GOVERNMENT SERVANT

1.I have not submitted any other claim far for Leave Travel Concession in respect of myself or my family members in respect of block of two years 20
............................................................. and 20...............................................

2.I have already drawn T.A. for the Leave Travel Concession in respect of a journey performed by me/ my wife with ................................................................. children.

3.I have not already drawn T.A. for the Leave Travel Concession in respect of a journey performed by me/my wife ........................................................... children/my
.................................................................... family members in respect of block of two years 20................................................... and 20.........................................

4.I have already drawn T.A. for the Leave Travel Concession in respect of a journey performed by me in the year ....................................................... in respect of block
of two years 20........................................ and 20.............................................................

This claim is in respect of a journey performed by me in the years ..........................................................................

This is against the concession admissible once year in a prescribed block for visiting home town as all the members of my family are living away from place of work.

5.This journey has been performed by me with my wife with ................................................................... children/my ............................................................................
family members to be declared home town viz. .....................................................................................

6.That my husband/wife is not employed in the Government.

That my husband/wife is employed in the Government service and the concession has not been availed of by him/her separately for himself/herself or for any of the
family members for the concerned block of two years.

7.Certified that my wife/husband for whom L.T.C. is claimed by me is employed in .............................................................................................................................

.............................................................................................................................................................................. Name of the Public Sector

Undertaking/Corporation/Autonomous body etc. which provides Leave Travel Concession facilities but he/she has nor preferred and will not prefer any claim in this
behalf to his/her employer.

8.Certified that my wife/husband for whom L.T.C. is claimed by me is not employed in any Public Sector Undertaking/Corporation/Autonomous body etc. financed
wholly or partly by the Central Government or Local Body which provides L.T.C. facilities to its employees and their families.

Place : SRO - Alkapuri Baroda Signature of Claimant :

Date : 04/12/2023
Signature of DDO :

For office use only

Admitted for Rs.

Objected to Rs.

Reasons For Objection

DA/OS/ADF/DDF/JDF/DF

Counter Signed :

Signature of Controlling Authority :