L.T.A.

APPLICATION
Name of the Employee
:
Employee Code
:
Designation
:
Department
:
Leave Sanctioned
: From ___________ to _____________ (__ Days)
Place of visit during leave period _______________________________
for which LTA is applied for.
Last LTA availed
_______________

for

the

leave

period

from

______________

To

List of My Family Members

Sl No

Name
of
the
Family member

Relationship

Mode of Travel

Fare

Kindly pay Rs. ________ (Rupees _____________________________________

_______________________) towards LTA for Calendar Year ________.
This is to state that the expenses mentioned above are incurred expenses for self
& dependent family members.
Place:
Date:

Signature:

FOR OFFICE USE ONLY

Passed
for
payment
of
Rs.__________/(Rupees______________________________________________________ only)
towards LTA.
Checked by:

AUTHORISED SIGNATORY