24417329 LTC TA GPF Medical Forms for Central Govt Employees

7/31/2019 24417329 LTC TA GPF Medical Forms for Central Govt Employees

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Application form for grant of LTC advance

1. Name of the Government Servant

2. Designation

3.Date of entering the Central Government

Service

4. PAY + SI + NPA

5. Whether permanent or temporary

6. Home Town as recorded in the Service Book

7.Whether wife / husband is employed and if

so whether entitled to LTC

8.

Whether the concession is to be availed for

visiting home town and if so block for which

LTC is to be availed.

9.

(a) If the concession is to visit anywhere in

India, the place to be visited.

(b) Block for which to be availed.

10.

Single rail fare/bus fare from the

headquarters to home town/place of visit by

shortest route.

Persons in respect of whom LTC is proposed to be availed.

S.No Name Age Relationship

1.

2.

3.

4.

5.

11.

6.

12.Amount of advance required. Rs.

I declare that the particulars furnished above are true and correct to the best of my knowledge. undertake to produce the tickets for the outward journey within ten days of receipt of the advance.

In the event of cancellation of the journey or if I fail to produce the tickets within ten days of receiptadvance, I undertake to refund the entire advance in one lump sum.

DateSignature of Government Serva


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G.A.R. 14-CSub Bill No._________

LEAVE TRAVEL CONCESSION BILL FOR THE BLOCK OF YEAR_____________TO_____

Note:-- This bill should be prepared in duplicateone for payment and the other as office copy.

PART A (To be filled up by Government Servant)


2. Designation

3. PAY + SI + NPA

4. Headquarters

5. Nature and period of leave sanctioned

From To

Particulars of members of family in respect of whom the L.T.C. has been claimed.

S.No.

Name (s) Age Relationship with the GovernmentServant

1.

2.

3.

4.

5.

6.

6.

7. Details of journey (s) performed by Government servant and the members of his/her family.

Departure Arrival

Date &

TimeFrom

Date &

TimeTo

Distancein Kms

Mode of Travel& class ofaccommodationused

No offares

Fairpaid

Remarks

8. Amount of advance, if any, drawn Rs.


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9. Particulars of journey (s) for which higher class of accommodation than the one to which the Governmenservant is entitled was used. (Sanction No. & Date to be given.)

Place Fare paid

From To

Mode of

conveyance

Class to which

entitled.

Class by

whichactuallytravelled

No of

FaresRs. P

10. Particulars of journey (s) performed by road between places connected by rail

Nature of Place Rail fare

From To

Class to whichentitled Rs. P.

Certified that the:-1. Information, as given above is true to the best of my knowledge and belief; and2. That my husband/wife is not employed in Government service / that my husband/wife is employed i

government service and the concession has not been availed of by him/her separately or himself/herseor for any of the family members of the concerned block of _____________Years.

Date_______________________

Signature of Government Servan

Part B ( to be filled in the Bill Section )

1. The net entitlement on account of leave travel concession works out to Rs._______________________ asdetailed below:-

(a) Railway/Air/Bus/Steamer fare Rs.______________________________(b) Less amount of advance drawan vide

Voucher No______________dated__________ Rs.______________________________________________________________________

Net Amount Rs.________________________________________

2. The expenditure is debitable to

Initial of Bill Clerk Signature of Drawing & Disbursing Office

Counter signed


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Signature of Controlling OfficerCertified that necessary entries have been made in the Service Book oShri/Shrimati/Miss______________________

Signature of the officer authorized to attesentries in the Service Book

Passed for Rs..Rupees..

Signature of Controlling Office

FOR USE IN ACCOUNTS BRANCH / PAY AND ACCOUNTS OFFICE

VOUCHER NODATED

Pay Rs..RupeesVide Cheque No.dated

Signature of the Drawing and Disbursing Office

LTC CERTIFICATECERTIFICATES TO BE GIVEN BY THE CONTROLLING OFFICER

Certified :

(i) that Shri/Shrimati/Kumari (Name of the Govt. Servant)Has rendered continuous service for one year or more on the date of commencing the outward journey.

(ii) that necessary entries as required under para 3 of the Ministry of Home Affairs O.M. No.43/1/55-Ests.(APart II dated 11th October, 1956 have made in the Service book of Shri/Shrimati/Kuma

Signature & Designation of the Controlling Office


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CERTIFICAT TO BE GIVEN BY THE GOVT. SERVANT

1. I have not submitted any other claim so for Leave Travel Concession in respect of myself or mfamily members in r/o the block of the yearsand

2. I have already drawn TA for the Leave Travel Concession in respect of journey performed bme/my wife with..children. The claim is in respect to the journey performeby my wife/myself with children none of whom traveled with the party othe earlier occasion.

3. I have not already drawn TA for the Leave Travel Concession in respect of a journey performeby me/my wife with..children/children in respect of thblock of two years..and ..This claim is in respect othe journey performed by my wife with..children/childrenone of whom availed of the concession relating to that block.

4. I have already drawn TA for the Leave Travel Concession in r/o a journey performed by me ithe yearin r/o of block of twyearsand.. This claim is in r/o of the journey performed by min the year..This is against the concession admissible once every yeain a prescribed block for visiting home town as all the members of my family are living awafrom place of work.

5. The journey has been performed by me/mwife..children/..children to the declare home tow

viz

6. That my husband/wife is not employed in Government.

That my husband/wife is employed in Government Service and the concession has not beeavailed of by him/her separately for himself/herself or for any of the family members for thconcerned block of two years.

7. Certified that my wife/husband for whom L.T.C. is claimed by me is employed i.(Name of the Public SectoUndertaking/Corporation/Autonomous body etc.) which provides Leave Travel Concessiofacilities but he/she has not preferred and will not prefer, any claim in this behalf from his/heemployer.

8. Certified that my wife/husband for whom L.T.C. is claimed by me is not employed in any PubliSector Undertaking/Corporation/Autonomous body financed wholly or partly owned by thCentral Government Local Body which provides L.T.C facilities to its employees and thefamilies.

Signature of Government Servan


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CONVEYANCE HIRE CLAIM


2. Designation

3. Officer / Section to which attached

4. Department Name

10. Particulars of journey for which conveyance is claimed.

Date of Journey &time

Particulars

Date Time From To

Mode ofconveyance

Distancein Kms

Purpose ofJourney

AmountSpent in

Rs.

1 2 3 4 5 6 7 8

Note:- In case of Taxi / Scooter hire the Registration No of the vehicle should be quoted and fare receipt benclosed.

Date____________ Signature of the Claimant___________________________________

Name and Designation of the Claimant________________________


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G.A.R. 14 -- A

Sub Bill No._________________

TRAVELLING ALLOWANCE BILL FOR TOUR

Note: - This bill should be prepared in duplicate one for payment and the other as office copy

PART A ( To be filled up by Government Servant )

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Certified that the information, as given above, is true to the best of my knowledge and belief.

( )

Signature of the Government Servant

Date____________________________


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'./&0&'/.1. Certified that I/my family was neither allowed free transit by Rail under free pass or otherwise provided with

means of communication at expense of the state or Local Bodies journey for which T.A. has been claimed in

this bill.

2. Certified that I/my family actually traveled by the class for which T.A. has been claimed in this bill.

3. Certified that the number of kilometers shown in the bill is in accordance with the poly maternal tables of the

establishment.

4. Certified that the journey on .was performed by Mail/Express train in the interest public

service.

5. Certified that I was actually not merely constructively in camp on Sundays and holidays for which daily

allowance is claimed.

6. Certified that I was not absent on Casual Leave during the period for which daily allowance has been claimed.

7. Certified during my halt at.from

. to while on inspection duty

continue to incur expenditure after the first 10 days.

8. Certified that I did not perform the road journey for which the kilometer allowance has been claimed at the

higher rates rule 46 of Supplementary rule by taking a single seat in a taxi/motor or mini bus or lorry playing

for hire.

9. Certified that I incurred running expenses in a car for which claimed in this bill for journey.

10. Certified that the road journeys for which kilometer has been claimed at the higher prescribed in

Supplementary rule 46 was performed by my own car.

11. Certified that the road journeys for which mileage is claimed were performed by road but were charged by rail.

The number of kilometers actually traveled by road being.

12. Certified that the family members for whom T.A. has been claimed actually travelled with me or followed me

on transfer. They were wholly dependent upon me & residing with me.

13. Certified that actual expenses incurred as cost or transportation of personal effects were not less than the sum

claimed in the bill.

14. Certified that I have transportedkgms. of

luggage on my transfer from.to..

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12/27

G.A.R. 14 -- B

[ See Rule 66 (1) & 90 (1), (I) ]

Sub Bill No._________________

TRAVELLING ALLOWANCE BILL FOR TRANSFERNote: - This bill should be prepared in duplicate one for payment and the other as office copy

PART A ( To be filled up by Government Servant )

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Date______________________ Signature of the Government Servant

Place______________________ Name___________________________


14/27

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'./&0&'/.1. Certified that I/my family was neither allowed free transit by Rail under free pass or otherwise provided with

means of communication at expense of the state or Local Bodies journey for which T.A. has been claimed in

this bill.

2. Certified that I/my family actually traveled by the class for which T.A. has been claimed in this bill.

3. Certified that the number of kilometers shown in the bill is in accordance with the poly maternal tables of the

establishment.

4. Certified that the journey on .was performed by Mail/Express train in the interest public

service.

5. Certified that I was actually not merely constructively in camp on Sundays and holidays for which daily

allowance is claimed.

6. Certified that I was not absent on Casual Leave during the period for which daily allowance has been claimed.

7. Certified during my halt at.from

. to while on inspection duty

continue to incur expenditure after the first 10 days.

8. Certified that I did not perform the road journey for which the kilometer allowance has been claimed at the

higher rates rule 46 of Supplementary rule by taking a single seat in a taxi/motor or mini bus or lorry playing

for hire.

9. Certified that I incurred running expenses in a car for which claimed in this bill for journey.

10. Certified that the road journeys for which kilometer has been claimed at the higher prescribed in

Supplementary rule 46 was performed by my own car.

11. Certified that the road journeys for which mileage is claimed were performed by road but were charged by rail.

The number of kilometers actually traveled by road being.

12. Certified that the family members for whom T.A. has been claimed actually travelled with me or followed me

on transfer. They were wholly dependent upon me & residing with me.

13. Certified that actual expenses incurred as cost or transportation of personal effects were not less than the sum

claimed in the bill.

14. Certified that I have transportedkgms. of

luggage on my transfer from.to..

'

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17/27

Performa for application for advance from Provident Funds

Application for Advance from G.P.F.

1. Name of the Subscriber

2. Account Number

3. Designation

4. Pay Rs.

Balance at Credit of the subscriber on the date of application as below:-

i Closing balance as per statement for the

year___________

Rs

ii Credit from _________to___________on

account of monthly subscription.

Rs

iii Refunds Rs

iv Withdrawals during the period from

__________to_____________

Rs

5.

v Net balance at credit Rs

6. Amount of advance/outstanding, if any, and the

7. Amount of Advance required

a. Purpose for which the advance is required

b Rules under which the request is covered

If advance is sought for House Building etc., following information may be given:-

i Location & measurement of the plot

ii Whether plot is freehold or on lease

iii Plan for construction

iv If the flat or plot being purchased isfrom a H.B. Society, the name of

Society, the location &measurement, etc.

v Cost of construction

c

vi If the purchase of flat is from DDA

or any Housing Board etc., the

location, dimension, etc., may be

given.

8.

d If advance is required for education of children, following details may be given:-


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i Name of the son / daughter

ii Class & Institution / College where

studying

iii Whether a day-scholar or a hostler

If advance is required for treatment of ailing family members, following details may

be given:-

i Name of the patient and

relationship

ii Name of the Hospital / Dispensary

/Doctor where the patient is

undergoing treatment.

iii Whether outdoor / indoor patient

e

iv Whether reimbursement availableor not

9 Amount of the consolidated advance (Items 6and 7 ) and number of monthly installments in

which the consolidated advance is proposed to

be repaid.

Rs.__________________in ________Installments.

10

.

Full Particulars of pecuniary circumstances of

the subscriber, justifying the application for the

advance

I certify that particulars given below are correct and complete to the best of myknowledge and belief and that nothing has been concealed by me.

Date:-

Signature of the Applicant

Name___________________________

Designation______________________

Section / Branch__________________

Note:- In case of advance under 8 to 8 (e), no certificate or documentary evidence would be required.


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APPLICATION FOR WITHDRAWAL FROM G.P.F.

1. Name of the Subscriber

2. Account Number

3. Designation

4. Pay Rs.

5. Date of Joining service and date of

Superannuation

Balance at Credit of the subscriber on the date of application as below:-

i Closing balance as per statement for theyear___________

Rs

ii Credit from _________to___________onaccount of monthly subscription.

Rs

iii Refunds made to the Fund after the closingbalance , vide (i) above

Rs

iv Withdrawals during the period from

__________to_____________

Rs

5.

v Net balance at credit on date of application Rs

6. Amount ofWithdrawal required

a. Purpose for which the withdrawal isrequired

8.

b Rules under which the request is covered

9 Whether any withdrawal was taken for the same

purpose earlier. If so, indicate the amount and theyear.

.

10.

Name of the PAO maintaining the Provident FundAccount

Date:-

Signature of the Applicant

Name___________________________

Designation______________________

Section / Branch__________________


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Annexure-D

Forms1

Form of Application for Final Payment/Transfer to Corporate Bodies/Other

Governments of Balances in the

General Provident Fund Account

To

The Pay and Accounts Officer,

_________________________,_________________________,

(Through the Head of Office)

Sir,

I am to retire/have retired have proceeded on leave preparatory to retirement for_________________________months/have been discharged/dismissed/have beenpermanently transferred to ________________________ / have resigned finally from

Government service/have resigned service under ___________________ Government to

take up appointment with ___________ and my resignation has been accepted with effectfrom _________________forenoon/afternoon. I joined service with______________

on______________forenoon/afternoon.

2. My Provident Fund Account No. is __________________________3. I desire to receive payment through my office through the

____________________Treasury/Sub Treasury. Particulars of my personal marks ofidentification left hand thumb and finger impressions ( in the case of illiterate subscribers

and specimen signature ( in case of literate subscribers) in duplicate, duly attested by a

Gazetted Officer of the Government, are enclosed.

PART-I

[To be filled in when the application for final payment

is submitted up to one year prior to retirement]

4. I request that the amount of Rs.________________ standing to the credit in myProvident Fund Account as indicated in the Accounts Statement issued to me for the yar

___________________(enclosed) / as appearing in my ledger account being maintained

by you_____________________________ Treasury/Sub Treasury/Head of Office, myplease be arranged to be paid to me as first installment of final payment.

5. * * * * * *


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6. After payment of the first installment of my Provident Fund balance, I will applyfor the payment of subsequent installments in Part-II of the form immediately on

retirement.

Yours faithfully

Signature-------------------------------

Station------------- Name________________________

Date:-___________ Address_____________________

This applies only when payment is not desired through the Head of Office.

( FOR USE BY HEADS OF OFFICES )

Forwarded to the Pay & Accounts Officer_________________________ for

necessary action.

2. The Provident Fund Account No.__________________ of Shri/Shrimati/Kumari(as certified from the Statements furnished to him/ her from year to year ) is

____________________________.

3. He/She is due to retire from Government Serviceon________________________________________________________.

4. Certified that he/she had taken the following advances in respect ofwhich______________________instalment of Rs._____________________are yet to berecovered and credited to the Fund Account. The details of the final withdrawals granted

to him/her are also indicated below:-

Temporary Advances Final Withdrawals

1._________________________ ___________________________

2. _________________________ ___________________________3. _________________________ ___________________________

4. _________________________ ___________________________

5. * * * * * *

Signature

of the Head of Office


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PART-II

[To be submitted by the Subscriber immediately after his/her retirement.

This Part is also applicable in the case of subscribers who apply for final payment for the

first time after the date of superannuation, discharge, resignation etc. ]

In continuation of my earlier application, dated___________________________,for the final payment of Provident Fund balances, I request that the entire balance at my

credit with interest due under the rules may be paid to me.

OrI request that the entire amount at my credit with interest due under the rules may

be paid to me /transferred to ____________________________________.

Signature-------------------------------

Name________________________

Address_______________________

( FOR USE BY HEADS OF OFFICES )

Forwarded to the Pay & Accounts Officer_________________________ for

necessary action/in continuation of Endorsement No. _____________ dated__________.

2. He/She has finally retired/ will proceed on leave preparatory to retirement for

_________________________months/have been discharged/dismissed/have beenpermanently transferred to ________________________ / have resigned finally from

Government service/have resigned service under ___________________ Government totake up appointment with ___________ and my resignation has been accepted with effectfrom _________________forenoon/afternoon. He/She joined service

with______________ on______________forenoon/afternoon.

3. The last fund deduction was made from his/her pay in this office billNo._______________, dated______________, for Rs.______________

(Rupees___________________________), cash voucher No._______________ of

__________________Treasury, the amount of deduction being Rs._________________and recovery on account of refund of advance Rs.___________________.

4. Certified that he/she was neither sanctioned any tempory advance nor any finalwithdrawal from his/her Provident Fund Account during the 12 months immediately

preceding the date of his /her quitting service under

_______________________Government/proceeding on leave preparatory to retirementor thereafter

or


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Certified that the following temporary advances/final withdrawals were

sanctioned to him/her and drawn from his/her Provident Fund Account during the 12months immediately preceding the date of his/her quitting service

under_________________________ Government/proceeding on leave preparatory to

retirement or thereafter

Amount of Advance/withdrawal Date Voucher number

1._________________________ ___________________________

2. _________________________ ___________________________

3. _________________________ ___________________________4. _________________________ ___________________________

5. * * * * * *6. It is certified that no demands/following demands of Government are due for

recovery

1

.

7. Certified that he/she has not resigned from Government service with priorpermission of the Central Government to take up an appointment in an other Department

of the Central Government or under a State Government or under a body corporateowned or controlled by the State2.

Signature

Of the Head of Office/Department

1. Certificate No.6 to be furnished in the case of Contributory Provident Fund Only.2. Please score out if not necessary.


24/27

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24417329 LTC TA GPF Medical Forms for Central Govt Employees

Documents

Transcript of 24417329 LTC TA GPF Medical Forms for Central Govt Employees