FORM–C

S.R. No.
UNITED INDIA INSURANCE CO. LTD.
REGIONAL OFFICE KOLKATA
( Claim for LTS Reimbursement )

1. Name of the Employee : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emp. No. . . . . . . . . . . . . . . . . . . . .

2. Designation and Department of Posting : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic Salary : Rs. . . . . . . . . . . . . .

3. Claim “Leave Travel Subsidy” in respect of myself and member / members of my family as shown below for the
outward/return journey for the block year 20 - 20 .

JOURNEY Admissible
Name of the person who
Sl. Date & time of amount by the
performed the journey and Mode of travel BALANCE
No. commencement From To FARE appropriate
relationship and class
of journey class

Certify that I have incurred the fares as shown above and that the information regarding Train Number and Ticket Numbers etc. given above is correct. I also
certify that I have not claimed previously Leave Travel Subsidy in respect of myself and / or members of my family whose names are mentioned above for
the above block year.
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enclo : . . . . . . . . . . . . . .
Advance drawn . . . . . . . . . . . . . . . . . . .
Place : . . . . . . . . . . . . . .
Net amount payable
Date : . . . . . . . . . . . . . . to me / refundable
by me . . . . . . . . . . . . . . . . . . . . . . . . . . . SIGNATURE OF THE EMPLOYEE
Leave taken for . . . . . . . . . . . . . . . days Amount payable / refundable as per bill Rs. . . . . . . . . . . . . . . . . . . . . .

Biswajit Chandra-12791 KRO

 from. . . . . . . . . . . . . . to. . . . . . . . . . . . . . Scrutinised by . . . . . . . . . . . . . . . . . . . . . . Checked by . . . . . . . . . . . . . . . . . . . . . . . . . .

PASSSED FOR PAYMENT / ADJUSTMENT Signature . . . . . . . . . . . . . . . . . . . . . . . . .

Designation . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Fare for . . . . . . . . Kms by . . . . . . . . Class Rs.. . . . . . . . . . . . .
(appropriate)

REMITTED / RECEIVED THE BALANCE OF RS. . . . . . . . . . .. . . . IN FULL AND FINAL

Subsidy per ticket for one journey : Rs. . . . . . . . . . . . . SETTLEMENT OF THE BILL

Total Subsidy : Rs. . . . . . . . . . . . .

Signature of the Employee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . .
(a) Amount Claimed : Rs.
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(b) Bill passed for : Rs.
Current I.T. Block years for LTS purpose . . . . . . . . . . . . . . . . . . To . . . . . . . . . . . . . .
(c) Advance paid : Rs.
-------------------------- Name of Home Town declared . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(d) Balance to be paid / receipted : Rs.
=============== LTS last availed and bill settled in the month & year . . . . . . . . . . . . . . . . . . . . . . . . . . .

Now availed & bill settled in month & year . . . . . . . . . . . amount Rs.. . . . . . . . . . . . . .

Less Amount Allowable for Home Town . . . . . . . . . . . . . . Rs. _____________

PAYMENT / RECEIPT
Particulars :
=============
Taxable Amount

Tax Rs. ________________ recovered in ________________

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NOTE : (1) Any journey consisting of travel by different classes, by train and / or by road and / or by sea and / or by air, each part must be written separately.
(2) Tickets or Cash Bill and vouchers are to be attached for both Onwards and Return journeys.
(3) Train Ticket numbers, train numbers and date of journey should be clearly stated wherever tickets or receipts are not produced.
(4) Mention must be made if the trip is for “HOME TOWN”.

Biswajit Chandra-12791 KRO