HexBPS 3204
Claim for Leave Travel Allowance
The Human Resource Department
Dear Sir/Madam,
Through: Departmental Head
This is to inform you that I have incurred the following expenditure on account of leave travel availed by me for
the calendar year ________ to _________. The necessary proof of travel is enclosed herewith for your records.
Kindly arrange to pay the same:
Sr. No. Names M/F Age Relationship Traveled Mode One-way Total
From To
1
2
3
4
5
6
Total :_________________ Rs. ___________________________________________________
________________________________________________ (in words)
I hereby declare that:
1. My wife, parents, children, brothers, sisters who traveled with me are entirely dependent on me.
2. The above information is true and I will completely be responsible for the income tax liability that may arise
on account my LTA claim which is being submitted.
3. I hereby declare that I have availed PL from _______________ to ___________________.
Thanking you
Yours faithfully,
----------------- ------------------------ ------------------------- ------------------------
Emp. No. Name Signature Date
HR Department Payroll/Accounts Department
Leave Availed: Amount to be passed :
Date of Joining: Amount to be exempted:
Amount to be taxed
Sanctioned by Sanctioned by
( Name & Sign ) ( Name & Sign )
Note: Please note that no LTA claim will be passed until it is enclosed with necessary supporting documents in
ORIGINAL.(only tickets are allowed)
LTA can be claimed on the completion of every year of service in the company
Exemption is limited to the Fare Expenses actually incurred for self and Family members of an employee, for travel to any
place in India. Family includes spouse and children and parents, brothers and sisters if dependent on the employee.
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Finance For Internal Use Only Version 1.1
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HexBPS 3204
Claim for Leave Travel Allowance
Amount of Fare exempt is limited up to First Class AC Rail Fare or Economy Class Air Fare or Public Transport Deluxe Bus
Fare.
Exemption is available for only 2 journeys in a block of 4 calendar years. Such Block, which is currently applicable, has
commenced on 1.1.2022 and will end on 31.12.2025.
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Finance For Internal Use Only Version 1.1
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