BILL NO DATE LEAVE TRAVEL CONCESSION BILL FOR THE BLOCK/CALENDAR YEAR __________ TO __________ PLACE OF VISIT : __________________________ NEAREST RAILWAY STATION /BUS STAND : ___________________________ PART - A (TO BE FILLED BY THE GOVERNMENT SERVANT) 1. Emp. Code _______________________ 2. Name __________________________ 3. Designation ______________________ 4. Basic Pay __________________________ (As on date of onward journey) 5. Headquarters ______________________ 6. Leave Details a) Nature of Leave __________________ b) Period ________________________ 7. Particulars of members of family in respect of whom the LTC has been claimed Sl.No Name Age Relationship 1 2 3 4 5 6 7 8 8. Details of journey(s) performed by Government Servant and the members of his/her family . Dep. Date & Place Arrival Date & Place Distance (Kms) Mode of Travel used Class of Accommodation No. of fares Fare Paid Ticket Nos PNR Nos Remarks 9. Amount of advance, IF ANY DRAWN Rs:-______________ 10. Particulars of journey(s) for which higher class of accommodation than the one to which the Government Servant is entitled was used. ( Sanction No. and date to be given) 11. Particulars of Journey(s) performed by the road between places connected by rail: Date & Place Mode of Conveyance Class to which Entitled Class by which Traveled No of fares Fare Paid Tickets (Nos) From To Date & Names of places Class to which entitled Fare Paid Tickets (Nos) From To Certified that : 1. The information are given above is true to the best of my knowledge and belief 2. That my husband /wife is not employed in Government service/that my husband /wife is employed in Government Service and the concession had not been availed of by him/her separately for himself/herself or for any of the family members for the concerned block year _____ to ______. 3. That my husband /wife for whom LTC is claimed by me is employed in ________________________________ (Name of the public sector undertaking/Corporation/Autonomous Body, etc.,), which provides leave travel concession facilities but he/she has not preferred and will not prefer any claim in this behalf to his/her employer; and 4. That my wife /husband for whom LTC is claimed by me is not employed in any Public Sector Undertaking / Corporation /Autonomous body financed wholly or partly by the central government or Local body, which provides LTC facilities to its employees and their families. 5. That my father/mother/sister/brother is /are fully dependent on me and their income is less than Rs 500 /-per month and he/she/they is/are residing with me. Dated : -Signature of Government Servant Name _________________________ Emp.Code _______________________ Telephone No_____________________ Intercom No______________________ Email ___________________________ CERTIFICATE TO BE GIVEN BY ADMINISTRATION 1.)Certified that necessary entries have been made in the service book of Shri /Smt /Kum 2.) Joint declaration/ certificate received from his/her husband's/ wife's office. He/She will avail LTC and other benefits from this office. Signature of the Officer Authorised to attest in the service book PART -B (To be filled by Bill section) 1. The net entitlement an account of Leave Travel Concession works out Rs __________________ Rupees (in words)_____________________________________________ a) Railway/Air/Bus/ Steamer Fare Rs _______________ b) Less Amount of advance drawn Rs _______________ Vide Bill No Dated ___________ Rs _______________ Net Amount _________ Rs _______________ 2. Expenditure is debit able to _______________________ Major head ________________________ Sub head ________________________ Drawing and Disbursing officer (Signature) Bill Clerk Initial
