Leave Travel Assistance (LTA) Claim Form

Name of the Employee:_xxxxxxx _ Emp. No._xxxxxx__Location: _xxxxx_

Date of Claim: _21
st
Aug. 2013.
Travel from Location: _Mumbai__ Travel Destination: Mahableshwar_
Travel from date: _21/08/2013_ To date:_26/08/2013_
Sr
No.
Name Age (in
case of
children/
Date of
Birth
Relation Date of Travel Mode and class
of travel
Actual fare
incurred (Rs)
1. Van
2. Van
3. Van
4. Van
5. Van
6.
Is LTA of earlier block i.e., calendar year 2010 2013 claimed in
current block Yes/No
Total amount claimed Rs._8500_/-
The current block of calendar year 2010-2013
LTA exemption claimed for
Total Travel Expenses incurred
LTA exemption claimed for
Travel during the period from _________ To _________
I hereby declare that all the expenses claimed above are in respect of journeys undertaken by me along with spouse/ parents/
dependent brothers and sisters by the mode and class of travel indicated above. I further declare that I have not claimed LTA exempt
under the income tax act, otherwise than indicated herein.
Signature of the Associate
NOTES:
1. If not otherwise mentioned by the employee, amount of LTA in respect of frst two journeys in block of four calendar years
commencing from 1
st
January 2010 would be tax-free.
2. If journey undertaken by the associate exceeds the shortest route fare to destination, in such a case, the associate will only be
eligible for exemption of the shortest route fare only.
a) If journey undertaken by air: Economy class air fare
b) If journey undertaken by train: First class air-conditioned train fare or Normal Train fare
c) If journey undertaken by public transport (train connection not available): 1
st
class or deluxe class of such transport.
d) If no public transport is available: Equivalent to frst class air-conditioned train fare.
For ofce use only
LTA considered exempt based on above claim Rs. _______________ Basis for computing exemption amount
Shortest route (in kms) for the above specifed destination
LTA considered taxable Rs. _______________
_____________ Kms
Amount of fare, as per the permitted mode and class of travel
Rs. _____________
(Approved by HR) (Checked & Certifed by fnance & Accounts)