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Railway : Proforma for submitting AILTC claims subsequent to performing journey - Annexure-III

Railway : Proforma for submitting AILTC claims subsequent to performing journey - Annexure-III

Annexure-III 
PROFORMA for submitting AILTC claims (subsequent to performing journey)

AILTC BILL FOR THE BLOCK 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 Railway Servant) 


S. No.
IName of Railway Servant
IIDesignation
IIIEmployee Number
IVPay and Pay Level
VHeadquarters
VINature and period of leave sanctioned
VIIDate of Submission of declaration/Intimation and PPSC to concerned ERB section.
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8. Particulars of members of family in respect of whom the AILTC has been claimed. 

S. No.Name(s) AgeRelationship with the Government Servant
I
II
III
IV
V
VI
VII

9. Details of Journey(s) performed by Railway Servant and the member of his/her family. 

DepartureArrivalDistance in KmsMode of travel and class of accommodation usedNo of FaresFare Paid
Date and TimeFormDate and TimeToRs./Ps
12345678

10. Amount of Advance, if any drawn : _______________________

11. Particulars of Journey(s) for which higher class of accommodation than the one to which the Railway Servant is entitled was used. 

PlaceMode of ConveyanceClass to which entitledClass to which actually travelledNo of FaresFare Paid Rs./Ps
FromTo
1234567
Date............................
Signature of Railway Servant................................ 

RUID No. .............................................................

Mobile No. ...........................................................

Encl: Original copy of all Bills to be submitted along with all tickets/air tickets and boarding passes in original dully stamped by the Airport Authorities. Photocopy of advance intimation is also to be submitted to concerned ERB Unit. 

Self Certification (Part B) 

I______________________________________Designation____________________________RUID No. ______________________Employee No.__________________________________Certify that: 

1. Information as given in Part 'A' relating to my AILTC claim is true to the best of my knowledge and belief.

2. l have not availed of any benefit other than air travel as a part of the package offered by the airline. 

3. That my husband/wife is not employed in Government I 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 ............................. years. 

4. 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. 

5. 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 by the Central Government or a Local Body which provides L.T.C facilities to its employees and their families. 

6. I have already drawn AILTC claim for the Leave Travel Concession in respect of journey performed by me/my wife with ................................... children. This 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. 

7. I have not submitted any other claim so far for Leave Travel Concession in respect of myself or my family members in r/o the block year ........................................................

Date:........................

Place: ......................

Signature of Railway Servant: ............................

Name:...................................................................

Designation/Branch: ...........................................

RUID No & Employee No:.................................

Mobile No. : .......................................................


Part - C ( to be filled by concerned Cash Section ) 

1. The net entitlement on account of leave travel concession works out to
Rs.
(a) Railway/Air/Bus/Steamer fare
Rs.
 (b) Less amount of advance drawn vide Voucher No______________ dated _____________________
Rs.
Net AmountRs.
 2. The expenditure is debitable to
Initials of Dealing hands
Signature of SO/Cash-I/II/III
Countersigned - US/Cash
 Signature of Controlling Officer-Dir/GA
Note: Before sending the final Bill to PAO the following certificate in Part(D) may be obtained from concerned ERB Section. As regards entry in Service Book of Gazetted Officers, the same be taken care of at the time of final clearing of LTC claim.

Part - D ( to be Given by Concerned ERB Section/PAO/RB ) 

1. Certified that Shri/Smt/Miss has rendered continuous service for four or more years on the date of commencing the outward journey & 

2. That necessary entries have been made m the Service Book of Shri /Smt /Miss ------------------------

Signature of the Officer authorized 
to attest entries in the Service Book - PAO/SO-ERB-I/Il/V 

For use in Pay and Accounts Office 

Voucher No ..................................... Dated .......................................... . 

Pay Rs. ............................... ........... Rupees ......................................... 

Vide . . ............... .................. .............Dated ........................................ . 

Signature of the PAO

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