PROFORMA TO BE APPENDED WHEN PROPOSALS FOR SANCTIONING LEAVE WITHOUT ALLOWANCE TO TAKE UP

EMPLOYMENT ABROAD/WITHIN THE COUNTRY/ACCOMPANY SPOUSE ABROAD WITHIN THE COUNTRY ARE
FORWARDED TO GOVERNMENT

1. Name and designation of the applicant :

2. Institution in which the applicant is working :
3. Date from which leave is required :
4. Duration of leave :
5. Purpose of leave :
6. Whether the appointment of the applicant in the
department is regular :
7. Total period of regular service put in by the applicant
in the Department on the date of application and
the date from which his/her continuous service
begins in the department :
8. Whether there is any disciplinary action pending :
9. Whether there is any bonded obligation or
contractual obligation. :
10. Whether there is any liability outstanding :
11. Whether the applicant has been sanctioned any
advances such as HBA/MCA etc. :
12. Whether the applicant has been sanctioned leave
for the same purpose earlier and if so furnish the
details :

13. Whether the applicant has been sanctioned leave

without allowances earlier for any purpose :
14. Whether any relaxation of rule is necessary to
sanction leave :
15. Whether you are convicted that suitable substitute
arrangements are easily available and if so,
whether a live list of candidates for appointment
is available with PSC :
16. Whether leave is recommended or not :
17. Leave address of the applicant in India :

18. Leave address of the applicant in abroad :

19. Any other relevant points to be brought to notice

of Government :

______________________ ___________________________________
Signature of Head of Office Counter signature by Sanctioning Authority
 (Page 2 of 12)

CHECK LIST

1. Name and designation of applicant with

full address :

2. Date of birth :

3. Date of commencement of continuous service :

4. Date of retirement :

5. Period of LWA applied for and date from which

applied for :

6. Purpose of leave :

7. Whether fresh application or extension, if extension

whether application in time :

8. Details of LWA taken previously for the same purpose :

9. Date of receipt of application by Head of Office :

10. Date of recommendation by Head of Office :

11. Date of counter signature by the controlling officer :

12. Date of dispatch of leave application :

13. Whether necessary certificates declarations are

furnished with the application :

14. a) Lien certificate from the manager :

b) Departmental NOC :
c) Declaration regarding liability :
d) Declaration regarding noninvolvement of
antinational activities :

15. Service Book of the employee with up to date entries :

16. Remarks :

______________________ ___________________________________
Signature of Head of Office Counter signature by Sanctioning Authority
 (Page 3 of 12)

DECLARATION

I, ………………………………………………………… do hereby declare that I shall not leave

India to take up employment abroad without prior permission of Government
of Kerala.

Place: _________________ Signature: _________________________

Date : _________________ Name: _________________________

Office: _________________ Designation: _________________________

Signature of Head of Office Counter Signature by

Sanctioning Authority
 (Page 4 of 12)

DECLARATION

I , ………………………………………………………………..………………… do hereby declare that

1. I have no bonded obligation to serve the department.

2. I also declare that no disciplinary action is pending against me.

3. It is also declared that I will not entertain in any propaganda which is against
the Government of India.

4. I will return to duty as and when the Government of Kerala call for me back.

5. I also undertake that I will abide by all conditions regarding the sanction of
leave now applied for.

Place: _________________ Signature: _________________________

Date : _________________ Name: _________________________

Office: _________________ Designation: _________________________

Signature of Head of Office

Counter Signature by
Sanctioning Authority
 (Page 5 of 12)

DECLARATION

I, …………………………………………, ……………….…………………………………..(designation)
do hereby declare that I have not been convicted by any court of Law for any
offence including moral turpitude.

Place: _________________ Signature: _________________________

Date : _________________ Name: _________________________

Office: _________________ Designation: _________________________

Signature of Head of Office Counter Signature by

Sanctioning Authority
 (Page 6 of 12)

DECLARATION

I, …………………………………………………………, ………………………………….. (designation)

………………………………..……..……..………. (office) do hereby declare that no
disciplinary action is pending against me.

Place: _________________ Signature: _________________________

Date : _________________ Name: _________________________

Office: _________________ Designation: _________________________

Signature of Head of Office Counter Signature by

Sanctioning Authority
 (Page 7 of 12)

DECLARAION

I, ……………………………………………, ………………………….…………………….. (designation)

………………………………...……..……..……….(office) do hereby declare that I have not
availed any loan or advance from Government and no liability is outstanding
against me.

Place: _________________ Signature: _________________________

Date : _________________ Name: _________________________

Office: _________________ Designation: _________________________

Signature of Head of Office Counter Signature by

Sanctioning Authority
 (Page 8 of 12)

DECLARATION

I, …………………………………………, ……………………………………………………..(designation)
………………………………...……..……..……….(office) do hereby declare that I am fully
aware of the fact that the leave without allowances now applied for if granted
will not be counted for any service benefits including pension and will be
recorded as such in the service book. It is also declare that I am prepared to
abide by all terms and conditions in Appendix XIIA Part I KSR.

Place: _________________ Signature: _________________________

Date : _________________ Name: _________________________
Office: _________________ Designation: _________________________

Signature of Head of Office Counter Signature by

Sanctioning Authority
 (Page 9 of 12)

DECLARAITON

I, …………………………………………………………, …………………………………..(designation)
………………………………...……..……..……….(office) do hereby declare that I will abide
by the Rules in Appendix XII A of G.O.(P) No 953/86/Fin Dated: 27/12/1986 and
its subsequent amendments.

Place: _________________ Signature: _________________________

Date : _________________ Name: _________________________
Office: _________________ Designation: _________________________

Signature of Head of Office Counter Signature by

Sanctioning Authority
 (Page 10 of 12)

DECLARATION

I, …………………………………………………………, …………………………………..(designation)
………………………………...……..……..……….(office) do hereby declare that I will abide
the conditions laid down in Appendix XII Part I KSR.

Place: _________________ Signature: _________________________

Date : _________________ Name: _________________________
Office: _________________ Designation: _________________________

Signature of Head of Office Counter Signature by

Sanctioning Authority
 (Page 11 of 12)

CERTIFICATE

Certified that no disciplinary action is pending against Sri

…………….……………………….……………., ……………………….……………………………………
(designation) ………………………………………………….. (Office) who have applied for
LWA for 5 years.

Place: _________________
Date : _________________

Signature of Head of Office Counter Signature by

Sanctioning Authority
 (Page 12 of 12)
Form No 13
APPLICATION FOR LEAVE
(Rule 113, Part – 1)
Note: Items 1 to 16 must be filled by all applicants whether Gazetted or Non Gazetted

1. Name of Applicant :
2. Date of birth :
3. Post held :
4. Department, Office, section :
5. Pay and scale of pay :
6. Date of entry in service :
7. Date of commencement of continuous service :
8. Whether applicant has got confirmation if any post if
so from which date and which post :
9. Address during leave :

10. HRA, Conveyance Allowance or other compensatory

allowance drawn in the present post :
11. Nature and period of leave applied for and date
from which required :
12. Sundays and holidays, if any proposed to be
prefixed/suffixed to leave :
13. Ground on which leave is applied for :
14. Date of return from last leave and the nature and
period of that leave :
15. a) I undertake to refund the difference between the leave salary drawn during commuted leave and that
admissible during half pay leave which would not have been admissible in the event of my retirement from service
at the end of during the occurrence of leave.
b) I undertake to refund the leave salary drawn during leave not due which would not have been admission had
rule 86, part 1 not been applied in the event of my voluntary retirement or resignation from service at any time
until I earn half pay leave not less than the amount or leave not due availed of by me.

16. Place: ________________________ Signature of Applicant with date

Date: ________________________

17. Remarks or Recommendation of the controlling officer :

Signature with date: _____________________________

Designation:____________________________________

CERTIFICATE REGARDING ADMISSIBILITY OF LEAVE

(By Accountant General (A&E) in the case of Gozetted Officer)
18. Certified that …………………………………………………………………………..…….…………………….…………………... (Nature of
leave) for……………………………….……………………………………………….………………. from ………………….……… admissible under
the rule ………………….. of KSR.

Signature (with date) Designation

19. Order of the sanctioning authority

Signature (with date) Designation