(a) ftvqlsr1qrrr

IITRFoTm-LTC-I
(FOR ES/GROUP'A')
crrufiqqtdFwltirerrqqm1
II{E}IAN INSTIT'UTE OF TECHNOLOGY ROORI{EE
ct-d?F-rri aiaT ftqrqa Ts sTFJq tg urne< va
APPI,iCATION FOR L.T.C.AND ITS ADVANCE
r.
o.frrt
2.
(m)'rs
id
uerti {)
Name of the Empioyee (in blocr< lltters)
6T qrn
Designation
(rg)
rqri e{erqr sfien{ (qR
eTre{r$
d d qqTid qi€ rid.{
iF-t)
Permanent or temporary
(lf not pennanent, surety bond from a permanent employee be
enclosed rvith application
(r)
adnn
(u)
offi dw
t
f++rs =n Wf q-ol
Full Address n'here presently residing
Employee
(a)
(v) tioolqFl
No
ftvqlsr1qrrr
Bank Name
(u) urot riwt
Department/Section
AccountNo
3.
edurr i-tis, trs i gq {fl n-ilr (+ gtftu)
Pay Band, Grade Pay. and Basic Pay (+ NPA)
4.
iircrn q ftgfu
d
frflr
Date of appointment in the Institute
5.
5.
t]-{r gk-6.r q qd d
Hometown as recorded in the service book
Ti{q-r
<Fr
elrq
fsr
rFr Erw EE q ftq rlg 3{tF5IvI qrfll ftqr+s d ft-flul
Particulars of LTC availed for previous block year
:
(o)
(D
7.
UE=r.n1ni uo-sa{
Hometown & Block
(s)
(iD
oi-dn fq qrc E{
Anyrvhere in India & block
qrqe
ii
trdqn su-s E{ gi riruu-s q{ ftiTfr sE frqr+d ti ot 3il-fqr ft-qt t
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
d/"fi
yesA'Io
9.
@r
ffi
ftqr rnn 3lttrrTrr sl-{r ftql-{a eTfrq Ttrd'
d ftl}l
qR
gtFHt
Whether LTC advance taken earlier has alreadv been settled in
ment of the previous advance.
.rqr
d
t
qr erff
t ? ffi
3fiJq
d
T,rdrc
full or pending settlement? Date of the settle
ro. o,rqt*q fusfr tr*Frt ts-o' d q-SlcR qR sTtr{d t? qR d, trq €d
qT fu-ift 3Trfud ctr{-{ rr*q d ftq oii LTc Et-Er lfr Au g1
sqTFrd ?Ftfu
s€ti
sTc-i ?Frqfarq
t rg{i
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.
qRcfrFfuolerciFftq-oilwq-oRdgft*t'qrifrcrt-iltc\wrtftq}swd'ritfuqasrie{Qrsl
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
12. qFit
-
13. ?rrril
tF,T
rfKrfrd r6't-{ tTflAE/EEr{ qrx (vomft)]
Type of Proposed journey by IBus/Train/Air (Economy)]
14. ?rFil 35qq 6-ri ?ff Ir{Trfuf, frfu
Proposed date of onward journey
rs.
Erqtff
qrfl
d
rroflftd
frft
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
/s\----A--,-----Afi\
-----J;
cnt (ctqilFQ
sl-dllcll<l
6lLrlt -A
ArJI
mo *io
*ltrlaV
+-qr snf*aH
Relationship
Name
S.No.
Date of
Birth
Whether
Dependents?
trrrF)tffior
sffinl
(Married/Unmarried)
(.
cnfleror ftqfrut
ts{rt$
#
i\
oirq
cR qre 3so0l- rrqn i{
sTf}r6
Tfr
(* Income from all sources should not exceed 3500i- per month to iiecide the dependency)
sqrttrHrfuoldsft Kr+frq1wqro'qt tq q-a zrRcl
All the columns of the above table should be explicitly filled up
gq
qtBq)
qtsqT
DECLARATION
t
sd{sTv
w
qcft frqwT qiq gq
vS t
ovor g/E-{ft
ifu tt
Hnr
ft}'d
sTd
d
sem
stir 9€
r
I
hereby cerlify that all particulars furnished on first two pages
of this LTC form
are true and correct.
t
eqTFT-d
qa qqq +drsi-ft
tfu s-€Irfrii qra ftqrq-o or sqdrq c qr{ cri d RqR t t gr< earyf er-oor r qrx ftqrqf,eTFJq G
;ro-A-+iurfr erc-{r ft \-{U ri slfrfl qqr o-{
W/Tfi
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.
t qe rt diqqr o-corlo-rfr
fucr qerq erfM fr xobqfr 6 t en+qq q ftfi€ {eTH zji erFdRtr erq
fu$ FQnq d qr*r
T€t 6-Fqr/o-{ift |
I also declare that I will not visit other than the place mentioned in the application
without obtaining prior approval of
the Competent Authoriry.
tfr
ti qa
't Son
o-s-dr/o-{ft
uw or q,n7qft
tfu .tgq ffi
d
so ft-d
d
er.q* qR
tfr qq$ qrx qS dr R-dt dr t
sTFrq
or
3rTrn
u,sq
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.
S zra ,ft srqr o-{dT/o-{fr
tfu
ffi
E'|{UtrM s{|Eo-
srD?T
{IFr frE..i
d
R?]ft q t srffi-s sfuo riftr re-{-{ trE
wT/qt
er_{rRT dt_dr
I also agree to refund balance amount to the office any case excess amount of
advance left with me for any reason
whatsoever.
riqrufit*ono.ror/a-{frtfuorFrqdiqfffrfU*GqrfldroR:iiderqrsrerflsffl311-9€{o-"qtT,-du-sfd,fi
q{ddl, slsicfuqndv{gidfuo-cailRd rrfi-+tds-qruru-*goovq'n/Ttt
d sqfr +ft srrrd A-d-{ ffi
* \ro-grd dI cFdcrd 6
er
* Eusrrrr W **r*
TdTdrrf,rtfrt{TrcE}iT{WsTFJq
qr wpo d w rrrofr t
r
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.
Udwer<Tdu|qorfttfusTq$qi-xfofrfldqoq$id ffd{qR sffiDrcrqnrRqiqoRoqqrrgfr-qrTqTdrgd
{rfu fr q-qfr d cFdcn d qq t qo-sr-iro ql wRn \-{ged tt or.rd +fl{ t eqn d qr sffi t
e-oFn
r
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
g* a-6 rt qcr t fu qR qraT Y$ dri d dH q&ii d ,tdi
R-o uqi r€i frt$ Tq dr n-ir qrqr ftrw dr e-o-dr t
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.
cW
I
ts-6Sqrf,arAilf{StfuqRd-q-dEridffiSerq-orqqaorsqdrqftqTqr16rtdreudvffig-sfrerdtCrfi
qqfu qrer fiffi
d qK, cr fu d-{iT sqTnr<r gQdi/*frei eilq-orfl ii
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
frci{
q-6l-{ o.r ffirFIqI Am-{
r
EKI&|{(Signature)
T{ (Designation)
q-qfr rgfrd q-*?rTq-{ ffii eqrm of sIEq slfq{qo'6Tffi tg
3r,IsTRf,
i t{no
vo/S/Sn-ft/go
R-d.qf,
Hi d effnl3rrofu.dFl
/
\,;-A ,,n , , f,\,, , \- *f"\-'
\E +
ql lgfqd
-s- #ffrTT rrcn 6/*ltglcl tllEcl t-ql?( Eg vllt{?(l \tlrqal df CilfSTRd fuql
-
t
d ftrS efitqq Rql
ci-q-flqr
TqT g
ftql qro t fr'
I
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
rirenqr
rffi
si-gqrq
d sdFr ig
For the use ofEstablishment Services Section
TF
t
frqo
e-6f{
drq-f,
total
to
from
Leave sanctioned Type
2" dtdq=i.1t B\rs 16 t TfrrrfrqfrRriiqt\'f-qqi.{dlqditdsaqfrqfr
t.
srq-oRT
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
sFr-.FRI
qrsfrq/Ts'r'r<d qqd vf,.&.fi. +q t
T6TT{/3Ifu-d
(home town/Anywhere/conversion of Home Town) LTC is due to
i
so-ss{d'ftc
In the Block Year
sce,wqd+iari
for the sub block year
5. qrfl6IT6|{
Mode of JourneY
6.
e.Radl
tg
d
d
3ID'q
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
o.6*o
Deating Asstt.
orsftero'
Supdt.
(s{fi)
(Adm.)
q6prrh e-dqRs / s'q goqfu-s
Asstt. Registrar/ Dy. Registrar
Edsnsm'sorq / g'aTalrsn (wr
DOFA
/
Dean (Adm
)
qrreq qlq\ffii {reTH s-.€-fr
s-sdl
slrrinm
qrx Rqrqo yq q€-d ftq
sTFJq
tg afaqq *
+sIt
gdsrq-fi (ft-trl-qdrtniT)
dq
ergwq
srtlFo
t
sTFJq
{rRr or
ft-*q
(orfUo-dq q-gqtFd
ffi
o.t soz,)
6d-qttr{st:-
odqt d awtert
o-{qtt ot iIrI :qq;iH,_
frqrq ,-
Rqio:-
gata-t:-
3r[sTRd