SHREE CEMENT LTD., BEAWARFORM OF DECLARATION

( Signature of the Employee )Date :

(Prescribed under the Leave Travel concession rules Shree Cement Ltd.)

Employee Name Employee Code

Date of Joining / ProbationDepartment

07-JAN-2016

FOR OFFICE USE ONLY1. Claim Period / Year

Form No

Mr. Himanshu Choubisa124521534

06-SEP-1202-1-RCP1-INSTRUMENTATION

Give the following particulars of each members of your family for whom you are eligible claim leave travel concession.

2. Amount of Previous Calender year Salary

3. Amount Claimed

:

Head Quarter Ras-Pali

Date of ConfirmationClaimed YearLeave availed

::::

:

: 01-MAR-2013

:

:

S.No Name Relation Age1

2

HAVIT CHOUBISA

KIRTI CHOUBISA

SON

SPOUCE

1.9

27

Give the name and address ( including district and state of your Home town )

Sai Street No. 5, Jai Hind Nagar, New Colony,Dungarpur,Rajasthan 314001,RJ,IN

Distance in Kms.By Rail / Road. Road

4732

Class of Travel. BY ROAD TOYOT

Visit Description : BEAWAR TO PONDICHERRY AND PONDICHERRY TO BEAWAR TAXI FARE4732 * 12 = 56784RS

FIFTY SIX THOUSAND SEVEN HUNDRED EIGHTY FOUR ONLY

Rs.

Rs.

4. Leave travel concession passed for 8% of S.No.2 Rs.

5. Advance taken Rs.

6. Net Amount Payable Rs.

Claimed Passed for Rs.

Folio No.

Debit :- LTA STAFF / WORKER Payment ( Rs.

LTC Journey Block : 2014-2017

Bill Amount in words:-

01-JAN-2015 TO 31-DEC-2015

YesBill attached :- NoApproval Required :-

I here by declare that the particulars furnished above are true and to the best of my knowledge and belief.

06-MAY-15 TO 17-MAY-15

56784.00Total Bill Amt :-

35865