Form - 1 APPLICATION FORM FOR GRANT OF L.T.C. ADVANCE 1. Name of the Government Servant 2. Designation 3. Date of entering the Central Govt. Service 4. Present Pay (Pay + Spl. Allowance) 5. Whether permanent or temporary 6. Hometown as recorded in the Service Book 7. Whether wife /husband is employed and if so whether entitled to L.T.C. 8. Whether the concession is to be availed for visiting Hometown, and if so block for which L.T.C. is to be availed 9. (a) If the concession is to visit "Any where in India", the place to be visited (b) Block for which to be availed 10. Single rail fare / bus fare from the headquarters to hometown / place of visit by shortest route 11. Persons in respect of whom L.T.C. is proposed to be availed Sno. Name and age Relationship 1. 2. 3. 4. 12. Amount of advance required Rs.............. 13. Proposed date of Journey I declare that the particulars furnished above are true and correct to the best of my knowledge. I undertake to produce the tickets for the outward journey within ten days of receipt of the advance. In the event of cancellation of the journey or if I fail to produce the tickets within ten days of receipt of advance, I undertake to refund the entire advance in one lump sum. Signature of Government Servant Designation Dated : DETAILS OF L.T.C. FOR ISSUE OF CERTIFICATE 1. Name of the Government Servant 2. Designation 3. Present Pay 4. Headquarter 5. Nature & period of leave sanctioned Nature_________From__________To_________ 6. Hometown as recorded in Service Book 7. Whether the concession is to be availed for visiting Home town or to visit "Any where in India" (b) Block for which concession availed 8. Particulars of Members of family in respect of whom the L.T.C. has been claimed S.No. Name Age Relationship with Govt. servant 1. 2. 3. 4. 5. 6. 9. Details of journey(s) performed by Govt. servant and family members of his/her family Date & Place Departure-Arival Distance in K.M. Mode of Travel Class of accommodation used No. of fares fare paid Ticket Nos. 10. Amount of Advance, if any, drawn : RS............... CERTIFIED THAT : 1. The information as given above is true to the best of my knowledge and belief. 2. That my husband / wife is not employed in Govt. service / that my husband / wife is employed in Government service and the concession has not been availed of by him / her separately for himself / herself or any of the family members for the concerned Block Year___________ to ___________. 3. That my husband / wife for whom L.T.C. is claimed by me is employed in_______________________(Name of the Public Sector Undertaking / Corporation / Autonomous Body etc.) which provides L.T.C. facilities but he / she not preferred and will not prefer, any claim in this behalf to his /her employer; and 4. That my wife / husband for whom L.T.C. is claimed by me is not employed in any Public Sector Undertaking / Corporation / Autonomous Body financed wholly or partly by central Government or a Local Body, which provides L.T.C. facilities to its employees and their families. Signature of Government Servant Designation Dated :
