LEAVE TRAVEL ASSISTANCE (“LTA”)

I want to take this amount as taxable (Please tick as applicable) ----Yes/No

(Those claiming Income Tax benefit on LTA (claiming non/partially taxable LTA) must compulsorily
fill up and submit Form12BB along with proof of travel, LTA will be taxable if the prescribed
documents will not attached.

This is to confirm that I have spent a sum of Rs 50000/-

_________ (Rupees ________________
Fifty Thousand only
_______________________________________________ only) which is eligible for LTA.

The details are as follows:

Dates of leave taken (from/to) NA

: _______________________________________

Dates of travel NA
: _______________________________________
NA
Place of origin of journey (Specify City) : _______________________________________

Place of destination (Specify City) NA

: _______________________________________

Distance in Kms (Mandatory) : NA

_______________________________________
Shortest & Farthest

Details of persons travelled:

Relationship with Journey fare
Name me Dependence (Y/N) in Rupees
1. Amit Kumar Pandey Self 50000
2.
3.
4.
5.
6.
Total
Summary of Supporting attached (Tick as Applicable)

1. Ticket – Air / Rail/ Bus -----

2. Boarding card for Air Travel -----

3. Invoice of Cab -----

4. Driver Duty Slip -----

09685374545
Signature : ___________________________ Mobile Number: ________________________
Amit Kumar Pandey IN010j15450
Name : ___________________________ Employee code: ________________________
Notes:
1. LTA can be claimed exempt from income-tax only in respect of two journeys performed
in a block of four calendar years. The current block of four years is 2014 - 2017.
2. The travel cost eligible for exemption would be for the shortest route to any place in India.
3. “Family” in relation to an individual, means -
(i) Spouse and children; and
(ii) Parents, brothers and sisters wholly or mainly dependent on the individual.
4. In case of Road Travel, distance allowed will be shortest distance to farthest location
------------------------------------------------------------------------------------------------------------------------
 FORM NO. 12BB

(See rule 26C)

Statement showing particulars of claims by an employee for deduction of tax under

section 192

1. Name and address of the employee: Amit Kumar Pandey

AQVPP4955G
2. Permanent Account Number of the employee:

3. Financial year:
2017-18

Details of claims and evidence thereof

Amount
Sl. Evidence /
Nature of claim
No. particulars
(Rs.)
(1) (2) (3) (4)
House Rent Allowance:

(i) Rent paid to the landlord

(ii) Name of the landlord

1.
(iii) Address of the landlord

(iv) Permanent Account Number of the landlord

Note: Permanent Account Number shall be furnished if the aggregate

rent paid during the previous year exceeds one lakh rupees
2. Leave travel concessions or assistance
Deduction of interest on borrowing:

(i) Interest payable/paid to the lender

(ii)Name of the lender

(iii) Address of the lender

3.
(iv) Permanent Account Number of the lender

(a) Financial Institutions(if available)

(b) Employer(if available)

(c) Others
4. Deduction under Chapter VI-A
(A) Section 80C,80CCC and 80CCD

(i) Section 80C

(ii) Section 80CCC

(iii) Section 80CCD

(B) Other sections (e.g. 80E, 80G, 80TTA, etc.) under Chapter VI-A.

Verification
Amit Kumar Pandey Om Prakash Pandey
above is complete and correct.
Raipur

(Signature of the employee)

Senior Associate Full N
Designati Amit Kumar Pandey