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FCC-HR-QFO-45
FCC CLUTCH
INDIA
L.T.A. REIMBURSEMENT FORM Rev.No. 0.0
Date 01.10.2016

Plant :
Name : Anjani Kumar Chaubay SAP No.: 27
Father's Name : Deep Narayan Chaubay
Designation : GM Department : NPD
Date of Joining : 25.Sep.2001
Preceeding Year Basic in December : ₹ 160,000.00
Year for which LTA is claimed : 2023- 24
Year and Month when it falls due : Dec-23
Earned Leave availed From 23 Dec -23 To 30.Dec.23 Days : 7
Place of visited : Varansi - UP
Class of Travel : By Air/By Rail/By Road : AIR
Approximate distance in Kms : 900 Km

DEPENDENTS ACCOMPANIED
S.No. Name Relation Age
1 Anjani Kumat Self 50

2 Madhu Chaubay wife 46

3 Somya Doughter 21

4 Arpil Son 19

Amount of Expense on fare : ₹ 96,000.00

Incidental Expenses during journey : ₹ 10,000.00
a) Conveyance : ₹ 20,000.00
b) Porterage : ₹ 40,000.00
c) Food : ₹ 25,000.00
Total Expenses : ₹ 191,000.00
Amount of LTA due :
Advance if any : ₹ -
Balance due/Payable :
Certified that Faridabad is my home town/within the distance of my home town as per clause 3 (A) (ii) of
the LTA Rules.

Date : 20.Jan.2024 Anjani Kumar

(Signature of Applicant)

……………………………….…………. ……………………………………….
(Recommended) (Approved)