Leave Travel Assistance Claim Form

Employee Name Name of Company

Emp. Code Designation Dept.
Duration of leave From To
Place of Travel From To
Date of Travel From To

Name (s) and Age of Family Members

Sr. Name Age Date of Relation Mode of Class of PNR Amount
No. birth (only Transport Travel/Car No./Air Rs._
for (Air/Train/ Model No. Ticket Mention
children) Car/Bus No.(**)/Car only
Invoice No. Traveling
(*) Fare
1 Self
2
3
4
5
6

I hereby certify that I have spent an amount of Rs. _________ (Rupees ____________________) towards Travel Fare expenses
for self, spouse and my dependents for traveling to ______________as per attached relevant supportings and details of
the travel. I am aware that the block of LTA is from 2018 to 2021 . Kindly allow exemption as applicable under the Income
Tax Act and pay me LTA as per my entitlements. .

Date Employee Signature

For HR Department Only - To confirm the number of payments taken by employee in a block as below.

Details of LTA Payment Details of LTA Payment

Year Date Signature Year Date Signature
2014 2018
2015 2019
2016 2020
2017 2021

LTA entitlement of Mr. / Ms. / Dr. _____________________________for the year _________to ________ is Rs.
______________Adjusted Rs.________________ against existing loan. Please pay Rs.__________ and account for Income Tax
as applicable.
HR Voucher No. Date Signature :

For Accounts Department only

Entitlement Exempted
Taxable Income Tax to be covered
Total Net payable
Signature

Note :
* The exemption will not be available for more than 2 children born after 01/10/1998
**Air fare is only applicable for Shortest Route for Domestic Travel as per National Airlines (i. e. Air India) and for
Economy Class only.