LTA Declaration Form
Emp Code –
Emp Name –
Dept –
Financial Year –
Employer - Pricol Limited
I_________________________________ s/o ____________________________ having PAN
No________________________ hereby declare that I have not claimed tax benefits on account
of LTA in my Income Tax Returns during the preceding 4 calendar years (2022-2025)
I agree to indemnify and hold the company free from any claim or charges of whatsoever nature
arising directly or indirectly in connection with the declaration provided and documentary
proof submitted.
Signature :
Date :
Leave Travel Assistance (LTA) Claim Form
Name of the Employee:
Emp. No.
Location:
Date of Claim:
Travel from Location: _______________________ Travel Destination:______________________
Travel from date: ______________ To date: _______________
S.No Name Age (in case of Relation Date of Mode and Actual fare
children/Date Travel class of incurred
of Birth travel (Rs.)
Is LTA of earlier block i.e., Calendar Year 2022 –2025 claimed in current Block: Yes/No
Total amount claimed Rs. _________ The current block of calendar year 2022-
2025
Total Travel Expenses incurred LTA exemption claimed for
Travel during the period from _________ To
_________
I hereby declare that all the expenses claimed above are in respect of journeys undertaken
by me along with spouse/ parents/dependent brothers and sisters by the mode and class of
travel indicated above. I further declare that I have not claimed LTA exempt under the
income tax act, otherwise than indicated herein.
Signature of the employee
NOTES:
1.If not otherwise mentioned by the employee, amount of LTA in respect of first two journeys
in block of four calendar years commencing from 1st January 2022 would be tax-free.
2.If journey undertaken by the associate exceeds the shortest route fare to destination, in
such a case, the associate will only be eligible for exemption of the shortest route fare only.
a) If journey undertaken by air: Economy class air fare
b) If journey undertaken by train: First class air-conditioned train fare or Normal Train
fare
c) If journey undertaken by public transport (train connection not available): 1st class
or deluxe class of such transport.
d) If no public transport is available: Equivalent to first class air-conditioned train
fare.
