Leave Travel Concession Claim Form

The Icfai Academy LEAVE TRAVEL CONCESSION CLAIM FORM To The Registrar Name:

Emp No. :

Designation:

Department :

Block period during which the concession is being availed of

Block period during which the concession was last availed of

Whether LTC Claim is for

Home Town

or

Another Place

(please specify)

Details of journey undertaken: Name

Relationship with employee

Age

Date of Journey

From

To

Distance

Mode/Fare Class of Travel

Onward Journey

i. ii. iii. iv Return Journey

i. ii. iii. iv

Total Amount claimed 1. 2. 3.

I certified that I am and members of my family are entitled to the Leave Travel Concession under the rules as claimed above and my family members are not entitled to this facility from any other source. The journeys for which the claim is made have actually been undertaken by the mode and class of travel indicated above. I have rendered more than one year of service.

Signature of Employee Countersigned by the Controlling Officer

(For Office Use Only) The above claim for Rs._____________________ has been verified and processed. Personnel Department Date:

Personnel Executive