Oracle Solution Services India Pvt Limited.

, LTA CLAIM / DECLARATION ORM This is to certify that I have incurred a sum of Rs.___________/- on performance of travel of myself and my family (i.e. spouse, children, dependent parents/brothers/sisters) while on leave from ____________ to __________________ as per the particulars iven below! Particulars o! Travel

1.
of Travel _____________ $ame of persons who traveled % e

"ri in of Travel _____________ #estination

Relationship

&rom / To (place)

'ode and (lass of Travel

%ctual fare) per head (both ways)

TOTAL I further clarify that the above *T% is the + st /,nd /-rd /.th admissible to me in respect of the /ourneys performed by me in the bloc0 of calendar years +.+.,1+1 - -+.+,.,1+- includin those *T%2s, if any received in my previous employment in the above bloc0. I further declare that the persons listed above are dependent on me. --------------------------------($ame of employee) -------------3mp. $o. ----------------------- ---------------------------#ate (4i nature of employee)

)$ote! The amount should be restricted to5

1. in case of travel by %ir, economy class air fare of the national carrier by shortest

route(air tic0et /ac0et to be enclosed.

2. in case of travel by other than %ir, fare by the shortest route (proof of travel to be

attached) Declaration !or "a#ment o! unclaimed / $alance LTA amount% I would li0e to claim all unclaimed / balance amount of my *T% eli ibility per option iven below! Unclaimed/Balance amount Till Dec 2013 [ ]

I understand that any unclaimed / balance amount paid to me will be net of ta6. --------------------------------($ame of employee) -------------3mp $o. ----------------------#ate ------------------------(4i nature of employee)