Application form for grant of LTC advance

1. Name of the Government Servant

2. Designation
Date of entering the Central Government
3.
Service

4. PAY + SI + NPA

5. Whether permanent or temporary

6. Home Town as recorded in the Service Book
Whether wife / husband is employed and if
7.
so whether entitled to LTC
Whether the concession is to be availed for

8. visiting home town and if so block for which

LTC is to be availed.
(a) If the concession is to visit anywhere in

9. India, the place to be visited.

(b) Block for which to be availed.
Single rail fare/bus fare from the

10. headquarters to home town/place of visit by

shortest route.
Persons in respect of whom LTC is proposed to be availed.
S.No Name Age Relationship
1.
2.
11. 3.
4.
5.
6.
Amount of advance required. Rs.
12.

I declare that the particulars furnished above are true and correct to the best of my knowledge. I
undertake to produce the tickets for the outward journey within ten days of receipt of the advance.

In the event of cancellation of the journey or if I fail to produce the tickets within ten days of receipt of
advance, I undertake to refund the entire advance in one lump sum.

Date
Signature of Government Servant.
 G.A.R. 14-C
Sub Bill No._________

LEAVE TRAVEL CONCESSION BILL FOR THE BLOCK OF YEAR_____________TO_____

Note:-- This bill should be prepared in duplicate—one for payment and the other as office copy.

PART – A (To be filled up by Government Servant)

1. Name of the Government Servant

2. Designation
3. PAY + SI + NPA
4. Headquarters
5. Nature and period of leave sanctioned

From To
6. Particulars of members of family in respect of whom the L.T.C. has been claimed.
S. Name (s) Age Relationship with the Government
No. Servant
1.
2.
3.
4.
5.
6.

7. Details of journey (s) performed by Government servant and the members of his/her family.
Departure Arrival Mode of Travel
Distance & class of No of Fair
Remarks
Date & Date & in Kms accommodation fares paid
From To
Time Time used

8. Amount of advance, if any, drawn Rs.

9. Particulars of journey (s) for which higher class of accommodation than the one to which the Government
servant is entitled was used. (Sanction No. & Date to be given.)
Place Mode of Class to which Class by No of Fare paid
conveyance entitled. which Fares
From To actually Rs. P.
travelled

10. Particulars of journey (s) performed by road between places connected by rail
Nature of Place Class to which Rail fare
From To entitled Rs. P.

Certified that the:-

1. Information, as given above is true to the best of my knowledge and belief; and
2. That my husband/wife is not employed in Government service / that my husband/wife is employed in
government service and the concession has not been availed of by him/her separately or himself/herself
or for any of the family members of the concerned block of _____________Years.

Date_______________________

Signature of Government Servant

Part – B ( to be filled in the Bill Section )

1. The net entitlement on account of leave travel concession works out to Rs._______________________ as
detailed below:-
(a) Railway/Air/Bus/Steamer fare Rs._______________________________
(b) Less amount of advance drawan vide
Voucher No______________dated__________ Rs._______________________________
________________________________________
Net Amount Rs.
________________________________________

2. The expenditure is debitable to

Initial of Bill Clerk Signature of Drawing & Disbursing Officer

Counter signed
 Signature of Controlling Officer
Certified that necessary entries have been made in the Service Book of
Shri/Shrimati/Miss______________________

Signature of the officer authorized to attest

entries in the Service Book.

Passed for Rs.………………………….Rupees……………..………………………………………………………………

……………………………………………………………………………………………………………………………………..

Signature of Controlling Officer

FOR USE IN ACCOUNTS BRANCH / PAY AND ACCOUNTS OFFICE

VOUCHER NO……………………………DATED……………………

Pay Rs…………………………………..Rupees………………………………………………………………………………
Vide Cheque No……………………………………….dated………………………………………………………………..

Signature of the Drawing and Disbursing Officer

LTC CERTIFICATE
CERTIFICATES TO BE GIVEN BY THE CONTROLLING OFFICER

Certified :

(i) that Shri/Shrimati/Kumari (Name of the Govt. Servant)…………………………………………………………………………

Has rendered continuous service for one year or more on the date of commencing the outward journey.

(ii) that necessary entries as required under para 3 of the Ministry of Home Affairs O.M. No.43/1/55-Ests.(A)
Part II dated 11th October, 1956 have made in the Service book of Shri/Shrimati/Kumari
…………………………………………………………………………

Signature & Designation of the Controlling Officer

 CERTIFICAT TO BE GIVEN BY THE GOVT. SERVANT

1. I have not submitted any other claim so for Leave Travel Concession in respect of myself or my
family members in r/o the block of the years…………………………………and…………………………………

2. I have already drawn TA for the Leave Travel Concession in respect of journey performed by
me/my wife with……………………………..children. The claim is in respect to the journey performed
by my wife/myself with ……………………………children none of whom traveled with the party on
the earlier occasion.

3. I have not already drawn TA for the Leave Travel Concession in respect of a journey performed
by me/my wife with……………………………..children/………………………children in respect of the
block of two years……………………………..and ………………………………..This claim is in respect of
the journey performed by my wife with……………………………..children/………………………children
none of whom availed of the concession relating to that block.

4. I have already drawn TA for the Leave Travel Concession in r/o a journey performed by me in
the year………………………………………in r/o of block of two
years…………………………and…………………….. This claim is in r/o of the journey performed by me
in the year……………………………………..This is against the concession admissible once every year
in a prescribed block for visiting home town as all the members of my family are living away
from place of work.

5. The journey has been performed by me/my

wife……………………..children/……………………………………..children to the declare home town
viz………………………………………………

6. That my husband/wife is not employed in Government.

That my husband/wife is employed in Government Service and the concession has not been
availed of by him/her separately for himself/herself or for any of the family members for the
concerned block of two years.

7. Certified that my wife/husband for whom L.T.C. is claimed by me is employed in

…………………………………………………………………………….(Name of the Public Sector
Undertaking/Corporation/Autonomous body etc.) which provides Leave Travel Concession
facilities but he/she has not preferred and will not prefer, any claim in this behalf from his/her
employer.

8. Certified that my wife/husband for whom L.T.C. is claimed by me is not employed in any Public
Sector Undertaking/Corporation/Autonomous body financed wholly or partly owned by the
Central Government Local Body which provides L.T.C facilities to its employees and their
families.

Signature of Government Servant

 CONVEYANCE HIRE CLAIM

1. Name of the Government Servant

2. Designation
3. Officer / Section to which attached
4. Department Name
10. Particulars of journey for which conveyance is claimed.
Date of Journey & Particulars Mode of Distance Purpose of Amount
time conveyance in Kms Journey Spent in
Date Time From To Rs.
1 2 3 4 5 6 7 8

Note:- In case of Taxi / Scooter hire the Registration No of the vehicle should be quoted and fare receipt be
enclosed.

Date____________ Signature of the Claimant___________________________________

Name and Designation of the Claimant_________________________

 G.A.R. 14 -- A
Sub Bill No._________________
TRAVELLING ALLOWANCE BILL FOR TOUR
Note: - This bill should be prepared in duplicate – one for payment and the other as office copy

PART – A ( To be filled up by Government Servant )

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( )
Signature of the Government Servant
Date____________________________
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1. Certified that I/my family was neither allowed free transit by Rail under free pass or otherwise provided with
means of communication at expense of the state or Local Bodies journey for which T.A. has been claimed in
this bill.

2. Certified that I/my family actually traveled by the class for which T.A. has been claimed in this bill.

3. Certified that the number of kilometers shown in the bill is in accordance with the poly maternal tables of the
establishment.

4. Certified that the journey on …………………….was performed by Mail/Express train in the interest public
service.

5. Certified that I was actually not merely constructively in camp on Sundays and holidays for which daily
allowance is claimed.

6. Certified that I was not absent on Casual Leave during the period for which daily allowance has been claimed.

7. Certified during my halt at………………………………………………………………….from

….……………………………… to ………………………………………………while on inspection duty
continue to incur expenditure after the first 10 days.

8. Certified that I did not perform the road journey for which the kilometer allowance has been claimed at the
higher rates rule 46 of Supplementary rule by taking a single seat in a taxi/motor or mini bus or lorry playing
for hire.

9. Certified that I incurred running expenses in a car for which claimed in this bill for journey.

10. Certified that the road journeys for which kilometer has been claimed at the higher prescribed in
Supplementary rule 46 was performed by my own car.

11. Certified that the road journeys for which mileage is claimed were performed by road but were charged by rail.
The number of kilometers actually traveled by road being…………………….…………

12. Certified that the family members for whom T.A. has been claimed actually travelled with me or followed me
on transfer. They were wholly dependent upon me & residing with me.

13. Certified that actual expenses incurred as cost or transportation of personal effects were not less than the sum
claimed in the bill.

14. Certified that I have transported………………………………………………………………………kgms. of

luggage on my transfer from………………………………………….to………………………………………..

'

$ 5 9 '!
 G.A.R. 14 -- B
[ See Rule 66 (1) & 90 (1), (I) ]

Sub Bill No._________________

TRAVELLING ALLOWANCE BILL FOR TRANSFER

Note: - This bill should be prepared in duplicate – one for payment and the other as office copy

PART – A ( To be filled up by Government Servant )

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Date______________________ Signature of the Government Servant
Place______________________ Name___________________________
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1. Certified that I/my family was neither allowed free transit by Rail under free pass or otherwise provided with
means of communication at expense of the state or Local Bodies journey for which T.A. has been claimed in
this bill.

2. Certified that I/my family actually traveled by the class for which T.A. has been claimed in this bill.

3. Certified that the number of kilometers shown in the bill is in accordance with the poly maternal tables of the
establishment.

4. Certified that the journey on …………………….was performed by Mail/Express train in the interest public
service.

5. Certified that I was actually not merely constructively in camp on Sundays and holidays for which daily
allowance is claimed.

6. Certified that I was not absent on Casual Leave during the period for which daily allowance has been claimed.

7. Certified during my halt at………………………………………………………………….from

….……………………………… to ………………………………………………while on inspection duty
continue to incur expenditure after the first 10 days.

8. Certified that I did not perform the road journey for which the kilometer allowance has been claimed at the
higher rates rule 46 of Supplementary rule by taking a single seat in a taxi/motor or mini bus or lorry playing
for hire.

9. Certified that I incurred running expenses in a car for which claimed in this bill for journey.

10. Certified that the road journeys for which kilometer has been claimed at the higher prescribed in
Supplementary rule 46 was performed by my own car.

11. Certified that the road journeys for which mileage is claimed were performed by road but were charged by rail.
The number of kilometers actually traveled by road being…………………….…………

12. Certified that the family members for whom T.A. has been claimed actually travelled with me or followed me
on transfer. They were wholly dependent upon me & residing with me.

13. Certified that actual expenses incurred as cost or transportation of personal effects were not less than the sum
claimed in the bill.

14. Certified that I have transported………………………………………………………………………kgms. of

luggage on my transfer from………………………………………….to………………………………………..

'

$ 5 9 '!
 Performa for application for advance from Provident Funds
Application for Advance from G.P.F.

1. Name of the Subscriber

2. Account Number

3. Designation

4. Pay Rs.

5. Balance at Credit of the subscriber on the date of application as below:-

i Closing balance as per statement for the Rs
year___________

ii Credit from _________to___________on Rs

account of monthly subscription.

iii Refunds Rs

iv Withdrawals during the period from Rs

__________to_____________

v Net balance at credit Rs

6. Amount of advance/outstanding, if any, and the

7. Amount of Advance required

8. a. Purpose for which the advance is required

b Rules under which the request is covered

c If advance is sought for House Building etc., following information may be given:-
i Location & measurement of the plot

ii Whether plot is freehold or on lease

iii Plan for construction

iv If the flat or plot being purchased is

from a H.B. Society, the name of
Society, the location &
measurement, etc.
v Cost of construction
vi If the purchase of flat is from DDA
or any Housing Board etc., the
location, dimension, etc., may be
given.
d If advance is required for education of children, following details may be given:-
 i Name of the son / daughter

ii Class & Institution / College where

studying

iii Whether a day-scholar or a hostler

e If advance is required for treatment of ailing family members, following details may
be given:-
i Name of the patient and
relationship

ii Name of the Hospital / Dispensary

/Doctor where the patient is
undergoing treatment.

iii Whether outdoor / indoor patient

iv Whether reimbursement available

or not
9 Amount of the consolidated advance (Items 6 Rs.__________________in ________
and 7 ) and number of monthly installments in Installments.
which the consolidated advance is proposed to
be repaid.

10 Full Particulars of pecuniary circumstances of

. the subscriber, justifying the application for the
advance

I certify that particulars given below are correct and complete to the best of my
knowledge and belief and that nothing has been concealed by me.

Date:-
Signature of the Applicant
Name___________________________
Designation______________________
Section / Branch__________________

Note:- In case of advance under 8 © to 8 (e), no certificate or documentary evidence would be required.
 Performa for application for withdrawal from Provident Funds
Application for Advance from G.P.F.

1. Name of the Subscriber

2. Account Number

3. Designation

4. Pay Rs.

5. Date of Joining service and date of

Superannuation

5. Balance at Credit of the subscriber on the date of application as below:-

i Closing balance as per statement for the Rs
year___________

ii Credit from _________to___________on Rs

account of monthly subscription.

iii Refunds made to the Fund after the closing Rs

balance , vide (i) above

iv Withdrawals during the period from Rs

__________to_____________

v Net balance at credit on date of application Rs

6. Amount of Advance required

8. a. Purpose for which the withdrawal is

required

b Rules under which the request is covered

9 Whether any withdrawal was taken for the same .

purpose earlier. If so, indicate the amount and the
year.
10 Name of the PAO maintaining the Provident Fund
. Account

Date:-
Signature of the Applicant
Name___________________________
Designation______________________
Section / Branch__________________
 Annexure-D
Forms
1
Form of Application for Final Payment/Transfer to Corporate Bodies/Other
Governments of Balances in the
General Provident Fund Account

To

The Pay and Accounts Officer,

_________________________,
_________________________,
(Through the Head of Office)

Sir,

I am to retire/have retired have proceeded on leave preparatory to retirement for

_________________________months/have been discharged/dismissed/have been
permanently transferred to ________________________ / have resigned finally from
Government service/have resigned service under ___________________ Government to
take up appointment with ___________ and my resignation has been accepted with effect
from _________________forenoon/afternoon. I joined service with______________
on______________forenoon/afternoon.

2. My Provident Fund Account No. is __________________________

3. I desire to receive payment through my office through the

____________________Treasury/Sub Treasury. Particulars of my personal marks of
identification left hand thumb and finger impressions ( in the case of illiterate subscribers
and specimen signature ( in case of literate subscribers) in duplicate, duly attested by a
Gazetted Officer of the Government, are enclosed.

PART-I
[To be filled in when the application for final payment
is submitted up to one year prior to retirement]

4. I request that the amount of Rs.________________ standing to the credit in my

Provident Fund Account as indicated in the Accounts Statement issued to me for the yar
___________________(enclosed) / as appearing in my ledger account being maintained
by you_____________________________ Treasury/Sub Treasury/Head of Office, my
please be arranged to be paid to me as first installment of final payment.

5. ******
 6. After payment of the first installment of my Provident Fund balance, I will apply
for the payment of subsequent installments in Part-II of the form immediately on
retirement.

Yours faithfully

Signature-------------------------------
Station------------- Name________________________
Date:-___________ Address_____________________
This applies only when payment is not desired through the Head of Office.

( FOR USE BY HEADS OF OFFICES )

Forwarded to the Pay & Accounts Officer_________________________ for

necessary action.

2. The Provident Fund Account No.__________________ of Shri/Shrimati/Kumari

(as certified from the Statements furnished to him/ her from year to year ) is
____________________________.

3. He/She is due to retire from Government Service

on________________________________________________________.

4. Certified that he/she had taken the following advances in respect of

which______________________instalment of Rs._____________________are yet to be
recovered and credited to the Fund Account. The details of the final withdrawals granted
to him/her are also indicated below:-

Temporary Advances Final Withdrawals

1._________________________ ___________________________
2. _________________________ ___________________________
3. _________________________ ___________________________
4. _________________________ ___________________________

5. ******

Signature
of the Head of Office
 PART-II
[To be submitted by the Subscriber immediately after his/her retirement.
This Part is also applicable in the case of subscribers who apply for final payment for the
first time after the date of superannuation, discharge, resignation etc. ]

In continuation of my earlier application, dated___________________________,

for the final payment of Provident Fund balances, I request that the entire balance at my
credit with interest due under the rules may be paid to me.
Or
I request that the entire amount at my credit with interest due under the rules may
be paid to me /transferred to ____________________________________.

Signature-------------------------------
Name________________________
Address_______________________
( FOR USE BY HEADS OF OFFICES )

Forwarded to the Pay & Accounts Officer_________________________ for

necessary action/in continuation of Endorsement No. _____________ dated__________.

2. He/She has finally retired/ will proceed on leave preparatory to retirement for
_________________________months/have been discharged/dismissed/have been
permanently transferred to ________________________ / have resigned finally from
Government service/have resigned service under ___________________ Government to
take up appointment with ___________ and my resignation has been accepted with effect
from _________________forenoon/afternoon. He/She joined service
with______________ on______________forenoon/afternoon.

3. The last fund deduction was made from his/her pay in this office bill
No._______________, dated______________, for Rs.______________
(Rupees___________________________), cash voucher No._______________ of
__________________Treasury, the amount of deduction being Rs._________________
and recovery on account of refund of advance Rs.___________________.

4. Certified that he/she was neither sanctioned any tempory advance nor any final
withdrawal from his/her Provident Fund Account during the 12 months immediately
preceding the date of his /her quitting service under
_______________________Government/proceeding on leave preparatory to retirement
or thereafter

or
 Certified that the following temporary advances/final withdrawals were
sanctioned to him/her and drawn from his/her Provident Fund Account during the 12
months immediately preceding the date of his/her quitting service
under_________________________ Government/proceeding on leave preparatory to
retirement or thereafter

Amount of Advance/withdrawal Date Voucher number

1._________________________ ___________________________
2. _________________________ ___________________________
3. _________________________ ___________________________
4. _________________________ ___________________________

5. * * * * * *

6. It is certified that no demands/following demands of Government are due for

recovery1.

7. Certified that he/she has not resigned from Government service with prior
permission of the Central Government to take up an appointment in an other Department
of the Central Government or under a State Government or under a body corporate
owned or controlled by the State2.

Signature
Of the Head of Office/Department

1. Certificate No.6 to be furnished in the case of Contributory Provident Fund Only.

2. Please score out if not necessary.
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