1. Name of the official (in block letters):

2. (a) Designation and Employee Code      :

   (b) Permanent or Temporary             : 
       [If not permanent Surety Bond 
       from a permanent official to
       be enclosed with the Application]

3. Unit/Office to which attached          :

4. Basic pay in the present grade         :

5. Date of appointment in the Department  :

6. Place of hometown as declared in the Service Book:

7. Particulars of LTC availed for        Block Year   
   prevoius  Block years               (i) Hometown
                                       (ii)Anywhere in India          

8. Block year for which now proposed to avail:

9. Whether avails CL or EL (Nature of leave to be mentioned):                       
10. Whether LTC advance already taken has
    been settled in full or pending settlement,
    date of the settlement of the prevoius case: 

11. Place of visit (farthest point)            :

12. Proposed date of onward journey            :

13. Probable date of return journey            :

14. Particulars  of family members availing the facility: 

      |                   |                 |      |
Sl.No.|     Name          |    Relationship |  Age | Whether Dependent 
      |                   |                 |      |
      |                   |                 |      |  
      |                   |                 |      |
      |                   |                 |      |
      |                   |                 |      |
      |                   |                 |      |
      |                   |                 |      |
      |                   |                 |      |
      |                   |                 |      |
      |                   |                 |      |
      |                   |                 |      |

15. Class of accomodation proposed to: 
    be availed in the Railway journey

16.  Amount of advance required      :

17. The office in which the spouse of:
    the G.S. is employed               

18. If the spouse is eligible for LTC :
    or similar concession from his 
    employer, whether declaration has 
    been given that he/she will not claim
    LTC himself/herself and family, from
    his/her office                     


                                  Designation and Emp. Code: 


      I __________________________ hereby certify that the above 
particulars furnished by me are true and correct.

      I also undertake to refund the LTC advance in full immediately 
in case of failure to perform the proposed journey for which advance
has been taken.

      I also declare that i will not visit other than the place 
mentioned in the application without obtaining prior approval of the 
competent authority.

      I also agree to refund one half of the advance if the return 
journey could not be performed within 90 days from the date of the 

      I also agree to credit forthwith to the office any excess amount 
of advance left with me for any reason whatsoever.

      I also agree to produce evidence of purchase of tickets, etc, for 
myself/members of my family as the case maybe for my forward journey
within 10 days or before the commencement of the journey whichever is 
earlier from the date of drawing the advance.I am aware that failure
to comply with the above repuirement will entail recovery of the 
advance in one lump sum from the next drawal of my salary ,together 
with the penal interest @2 1/2% over and above the normal interest.

     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 penal interest
@2 1/2 over and above the normal interest.

    I am also aware that my claim will be forfeited if I fail to submit
the bill within 3 months from the date of completion of the journey.

    I also understand that if the LTC is availed for self the cost is
reimbursable only when the journey is performed after availing any 
kind of leave and not during weekend holidays/other holidays/R.H. 

                                Designation and Emp. Code:

                  REMARKS OF THE UNIT OFFICER      

 Forwarded.  Official applied CL/EL as at Col. 9 and the same has 
             been santioned.

                                        Unit Officer