LTA Claim Form

Employee Name : Employee Code :

Date of Joining : Grade :

Location : Privilege Leave Date (From) :

Privilege Leave Date (To) : Privilege Leave Days :

LTA Details :

Journey Start Date :

Journey end Date :

Sr. No. Date Location From Location To Mode of Travel Travel Fare Remarks

Family Details : (Required only if employed traveled along with family).

Sr. No. Name of Family member Relation with Family Dependant on employee (Yes or
member No)

Date : Employee Signature :

Note : Pls. attach original travel bills. In case of air travel, boarding pass is must.