LEAVE TRAVEL ASSISTANCE CLAIM FORM

To Dated:__________________

The Payroll Department

Employee ID:

Employee Name: Location:

Date of Joining: Process Name:
Name of HR SPOC: Designation:

LTA being claimed for the year Financial year 2016-17

Number of Approved Leaves
Period of Approved Leaves
From__________ ___ To _____________

Entitlement of LTA Rs. :___________________

(Refer your appointment letter or call HR Direct advisor, if required)

Mode of Travel (Air / Train/ Car) :___________________

Total no. of persons travelled :___________________

Total expenditure incurred on Fare Rs. :___________________

 Self Declaration on dependents

Please mention the names and relationship with you who have accompanied you on
travel (if any), certifying that they all are dependent on you.
(Kindly note that benefit for in laws is not allowed)

Name Relationship with Employee Age

Tour Plan:
MODE OF TICKE
DISTANCE IN TRANSPORT USED TS
KM (IF (AIR, RAIL, BUS, ATTAC
S.NO. SOURCE DESTINATION POSSIBLE) OTHERS) AMOUNT HED
1 Y/N:
2 Y/N:
3 Y/N:
4 Y/N:
5 Y/N:
6 Y/N:
7 Y/N:

I certify that the above information is true and correct.

Also certify that I have utilized Leave Travel Assistance towards the expenses on me and
my family as per my entitlement.

Yours Faithfully,

______________________
Signature of the Employee
Guidelines:

In case of travel through Air - Please ensure that ORIGINAL TICETS &
BOARDING PASSES are attached. In case of failure to do so the tax benefit will
not be provided.
In case of air tickets, no benefit will be provided unless boarding passes are
attached.
In case of travel through Taxi Please submit the invoice / bill in original, tax
benefit will be rejected if photocopy is submitted.
LTA tax benefit is only allowed for the travel within India and not for outside
India.
The Employee shall ensure that they travel along with the family members,
otherwise benefit will not be provided.
If multiple journeys are performed then fill the above table carefully, separate line
for each journey. For e.g. Delhi- Jaipur Mumbai - Delhi. Then entry should be:
1. Delhi Jaipur; 2. Jaipur Mumbai and 3. Mumbai to Delhi.
No need to breakdown the Distance and Amount column.
Where journey is performed by Air: The amount of exemption cannot exceed
air economy fare of the National Carrier by the shortest route of the amount spent
whichever is less.
Where journey is performed by Train: The amount of exemption cannot
exceed air conditioned first class rail fare by the shortest route of the amount
spent whichever is less.
Where journey is performed by Car: The amount of exemption cannot exceed
air conditioned first class rail fare by the shortest route of the amount spent
whichever is less.
Exemption is available only pertaining to the fare. No other charges are to be
included.