1. The document is an application form for Leave Travel Assistance from Mitsubishi Electric India Pvt. Ltd. An employee is applying for LTA claiming expenses incurred traveling with family members during their leave period. 2. The employee provides details of the leave availed, travel dates, monthly salary, total fare expenses, starting and destination points of travel, and mode of travel. 3. The employee declares the amount of LTA they are eligible for a tax exemption on and takes responsibility for producing necessary documents to authorities and paying any income tax liability that may arise from the LTA amount.

1. Mitsubishi Electric India Pvt. Ltd.
Leave Travel Assistance
Cl. No. 6.2.2
Application for Leave Travel Assitance
Employee Code: --------------------------
Employee Name: --------------------------------------------------------------------------------
Department: ------------------------------------------------------------------ Location:---------------------
Dear Sir/Madam,
Kindly arrange to pay me Leave Travel Assistance for the year on travelling during the leave period
mentioned below:-
1. No. of leaves availed: ________
2. From (Date):_________ To (Date):__________
3. Please include the amount of my monthly salary and deduct income tax as applicable.
4. I have not incurred expenses travelling / I shall avail the Tax exemption in the next year
(Strike whichever is not applicable)
5. I have incurred total fare of Rs. __________/- for traveling in India with my family members
(Family members include – Spouse / Children /mainly dependant parents / brothers and sisters)
during my leave period.
Details of journey undertaken by me during my leave period along with my family members are
as follows:-
Name Relationship
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2. Mitsubishi Electric India Pvt. Ltd.
Leave Travel Assistance
Cl. No. 6.2.2
Starting Point of Journey :
Destination :
Mode of Travel :
Total Expenditure on To & Fro journey:
I have verified and understood the conditions stated overleaf and I declare that out of total LTA
payable to me, I am eligible for exemption of Tax under Income Tax Act on an amount of
Rs.____________/-
Therefore please do not deduct income tax from the said amount. I shall be fully responsible to
produce the necessary evidence to this effect as and when required. If any issue arises by the Income
Tax authorities in case of my income tax liability on account of Leave Travel Assistance, I undertake
discharge of the same.
Signature of the Employee:
For Finance purpose:
Voucher No. Date:
Processed By:
Passed By:
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