The Icfai Academy

LEAVE TRAVEL CONCESSION CLAIM FORM

To
The Registrar

Name: Emp No. :

Designation: Department :

Block period during which Block period during which

the concession is being the concession was last
availed of availed of

Whether LTC Claim is for Home Town or Another Place (please specify)

Details of journey undertaken:

Name Relationship Age Date of From To Distance Mode/Fare
with Journey Class of
employee Travel
Onward Journey

i.
ii.
iii.
iv

Return Journey

i.
ii.
iii.
iv

Total Amount claimed

1. 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.
2. The journeys for which the claim is made have actually been undertaken by the mode and class of travel indicated above.
3. 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