Leave Travel Concession (LTC) Cash Voucher Scheme Application Form
Application Form for Special Cash Package in Lieu of LTC
LTC Fare + 10 Days EL Encashment During Block Year 2018-21
Name / Designation of the Government Servant:
Date of entering the Government Service:
Basic Pay: Rs.
Pay Matrix Level:
Whether Permanent of Temporary:
Home Town as recorded in Service Book:
Whether wife / Husband is employed And if so whether entitled to LTC:
Whether the concession is to be surrendered for visiting Home-Town, and if so block year
If the concession is to be surrendered “anywhere in India” Block year proposed to be surrendered:
Single Deemed LTC fare:
Whether advance is required: Yes / No
Persons in respect of whom LTC is proposed to be availed:
| Sl.No. | Name | Age | Date of Birth | Relationship | Block year to be availed |
| 1 | |||||
| 2 | |||||
| 3 | |||||
| 4 |
I declare that the particulars furnished above are true and correct to the best of my knowledge. I undertake to produce the receipts towards the purchase or availing goods and services which carry a GST rate of not less than 120/0 from GST registered Vendors/ Service providers through digital mode indicating clearly the GST number and the amount of GST paid.
In the event of cancellation of the application or if I fail to produce the valid receipts within the stipulated time frame, I understand to refund the entire advance in one lump sum along with penal interest as applicable.
Name of the Bank:
Saving Bank Account No.:
IFSC Code:
Branch MICR Code:
Date:
Signature:
Name:
Designation: