LEAVE TRAVEL ASSISTANCE DECLARATION FORM:

To
The Payroll Department

Employee's Payroll Code

(As shown on the Payslip)

Dear Sir,

I,

hereby declare the following with respect to

Leave Travel Assistance claimed by me during the block January 1, 2014 to December 31, 2017.

LTA claimed on Taxable Basis

LTA claimed on Non-Taxable Basis

(If Yes then mention amount

(If Yes then mention amount

and the date of travel)

and the date of travel)

January 1, 2014 to

Yes / No

Yes / No

December 31, 2014

Date

Date

Rs.

Rs.

January 1, 2015 to

Yes / No

Yes / No

December 31, 2015

Date

Date

Rs.

Rs.

January 1, 2016 to

Yes / No

Yes / No

December 31, 2016

Date

Date

Rs.

Rs.

January 1, 2017 to

Yes / No

Yes / No

December 31, 2017

Date

Date

Rs.

Rs.

Period

I certify that the above information is true and correct.

Yours faithfully,

Signature of Employee

LTA Declaration.xls LTA Declaration 28/09/2015