1. No category

IITRFoTm-LTC-I
(FOR ES/GROUP'A')
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II{E}IAN INSTIT'UTE OF TECHNOLOGY ROORI{EE
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APPI,iCATION FOR L.T.C.AND ITS ADVANCE
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Name of the Empioyee (in blocr< lltters)
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Designation
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Permanent or temporary
(lf not pennanent, surety bond from a permanent employee be
enclosed rvith application
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Full Address n'here presently residing
Employee
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No
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Bank Name
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Department/Section
AccountNo
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Pay Band, Grade Pay. and Basic Pay (+ NPA)
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Date of appointment in the Institute
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Hometown as recorded in the service book
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Particulars of LTC availed for previous block year
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Hometown & Block
(s)
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Anyrvhere in India & block
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GEreqqd : (zot+-tt) (zot+-tslzo16-17) qfw ii erqr/lra =rn
Block year & Sub block year for which LTC now applied to avail
Eg: (2014-17) (2014-1512016-17 Any where/Home Town)
In case of first time recruits in govt. service,
Yearly proposed LTC eg. home town 20141201512016/ home town/any where 2017)
(Details of LTC availed in preview organization before joining IIT Roorkee),
B. (D
3rr?hrnqrildetro uaorudu-qft, sFrorrl 3Trnfi dtnts
Nature of Leave proposed to avail i.e.; CL or EL or other during LTC with leave application
(ii) 10 fuild GffinTfl qo+rr,'r qRd
With 10 days leave
encashment
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Whether LTC advance taken earlier has alreadv been settled in
ment of the previous advance.
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full or pending settlement? Date of the settle
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sqTFrd ?Ftfu
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That whether husband/wife is employed in govt. service. If yes, self certifu that LTC has not been availed by
him/her separately for himself/herself or for any of the family member from her/his employer.
11.
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c{Ti cf{R d ftiln sTci ?FTqhq t crq-+rri qrx frqrqo 6r qtn rfi eirn/Etrt
If the spouse have an eligibility for LTC from herihis employer then one time Decleration that she/he will not
claim LTC for self / any family member frorn her/his employer.
OK1ft-a em (qren rera)
Place of proposed visit (Farthest point)
Any where / Home town
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13. ?rrril
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Type of Proposed journey by IBus/Train/Air (Economy)]
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Proposed date of onward journey
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Probable date of return journey
16. Es EfrEr o,t srqttT ori sT-e cfrfl{ d rr<rsi ot ft-asul
to be availed (including / excluding Se f)
Perso ns in respect of whonr LTC in
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Relationship
Name
S.No.
Date of
Birth
Whether
Dependents?
trrrF)tffior
sffinl
(Married/Unmarried)
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(* Income from all sources should not exceed 3500i- per month to iiecide the dependency)
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All the columns of the above table should be explicitly filled up
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DECLARATION
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I
hereby cerlify that all particulars furnished on first two pages
of this LTC form
are true and correct.
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I also undertake to refund the LTC advance and leave encashment amount in
full immediately in case of failure to
perform the proposedjourney for which advance has been taken.
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I also declare that I will not visit other than the place mentioned in the application
without obtaining prior approval of
the Competent Authoriry.
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I also agree to refund half of the advance if the return journey could not be performed
within 90 days from the date
ofthe
advance.
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I also agree to refund balance amount to the office any case excess amount of
advance left with me for any reason
whatsoever.
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I also agree to produce evidence of purchase of tickets, etc. for myself/members of
my family as the case may be for
the forward journey within 10 days or before the commencement of the joumey whichever
is earlier from the date of
drawing the advance. I am aware that failure to comply with the ablve reiuirement will
entail recovery of the
advance in one lump-sum from the next drawal of my salary together with thepanel
interest @2 percentover GpF
interest on the entire advance.
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I am aware that if I do not submit LTC bills within one month from the date of return journey, the
outstanding LTC
advance is recoverable in one lump-sum from my next salary together with the panelinterest
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I am also aware that my re-imbursement claim, if no-advance drawn will be forfeited if I fail to submit the
bills within
3 month from the date of completion ofjoumey.
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I also understand that if the LTC is availed for self the cost is reimbursable only when the journey is performed by
availing any kind of leave and not during week-end holidays/ R.H. alone
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Recommended and forwarded to Establishment Services Section for further necessary action that
Dr./Shri/Smt./Km.
to
w.e.f.
has
applied
days
EL/CL
I
which has been sanctioned/forwarded to the competent Authority for
sanction.
frq-rrE{amqrq'el
Head of the DeptVOffice
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For the use ofEstablishment Services Section
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total
to
from
Leave sanctioned Type
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Entries from
3.
4.
gcTRi
Days
cl I to 8 and 16 have been checked and found correct.
To€fosur
Encashment of
Rc €rqd/qd-qdl3lidfi T€tftqr
days approved,Alot approved Not applied
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T6TT{/3Ifu-d
(home town/Anywhere/conversion of Home Town) LTC is due to
i
so-ss{d'ftc
In the Block Year
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for the sub block year
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Mode of JourneY
6.
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Advance to the extent of admissibilify in respect
7.
of
Persons is approved
Book
Necessary entries have been made by me (the Dealing Assistant) in the Service
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Deating Asstt.
orsftero'
Supdt.
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(Adm.)
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Asstt. Registrar/ Dy. Registrar
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DOFA
/
Dean (Adm
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