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LTA MEDICAL REIMBURSEMENT FORMS

The document is a medical expense reimbursement form submitted by Hardik Shah, an executive employee, for medical expenses incurred by his wife Parveen Shah from November 2016 to January 2017 totaling Rs. 7,630. It provides details of 7 medical bills, including dates, bill numbers, patient's name and relationship to employee, and amounts. The form requires signatures for approval from HR and Finance departments.

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Hardik
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85 views3 pages

LTA MEDICAL REIMBURSEMENT FORMS

The document is a medical expense reimbursement form submitted by Hardik Shah, an executive employee, for medical expenses incurred by his wife Parveen Shah from November 2016 to January 2017 totaling Rs. 7,630. It provides details of 7 medical bills, including dates, bill numbers, patient's name and relationship to employee, and amounts. The form requires signatures for approval from HR and Finance departments.

Uploaded by

Hardik
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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EMAMI LIMITED

Medical Expense Reimbursement Form


DD MM YY
19 1 2017
Department
Finance & Accounts
Name: HARDIK SHAH Empl. Code: 90003932
Designation: EXECUTIVE Location HO

Details of Medical Expenses:


Sl.
Relationship
No Date Bill No Name of Patient Amount (In Rupees)
with Employee
.
1 01.11.2016 31859 PARVEEN SHAH WIFE Rs. 800.00
2 04.01.2017 87817 PARVEEN SHAH WIFE Rs. 900.00
3 10.12.2016 81570 PARVEEN SHAH WIFE Rs. 800.00
4 24.12.2016 85216 PARVEEN SHAH WIFE Rs. 1,100.00
5 18.01.2017 91477 PARVEEN SHAH WIFE Rs. 900.00
6 25.08.2016 51902 PARVEEN SHAH WIFE Rs. 1,130.00
7 24.09.2016 61832 PARVEEN SHAH WIFE Rs. 2,000.00
TOTAL Rs. 7,630.00
Total amount in words: SEVEN THOUSAND SIX HUNDRED THIRTY ONLY

The original medical bills are attached herewith. Medical reimbursement will be taxable if the
prescribed proof of purchase is not attached

Date 19.01.2017 Signature


================================================================================

(For Internal Use only)

Approved By:

For HR:
Date:

For Finance:
Date:
EMAMI LIMITED

LEAVE TRAVEL ASSISTANCE CLAIM FORM


DD MM YY

18 9 2017
Department
Finance & Accounts
Name: HARDIK SHAH Empl. Code: 90003932
Designation EXECUTIVE Location HO
This is to confirm that I have spent a sum of Rs.25,100 (Rupees Twenty one thousand five hundred only) which is
eligible for LTA.

Date of leave From


taken 14th August 2017 To 16th August 2017

From
Date of travel 14th August 2017 To 17th August 2017

Place of Origin of journey Kolkata Place Visited Ahmedabad

Mode of Travel Air Approximate Distance Kms


Details of Travel Expenses:
Sl.
Relationship
No Date Bill No Name Amount (In Rupees)
with Employee
.
1 14-Aug-17 D5LV8C HARDIK SHAH SELF Rs. 12550
2 17-Aug-17 D5LV8C HARDIK SHAH SELF Rs. 12550
3
4
TOTAL Rs. 25100
Total amount in words: Thirty two thousand three hundred ninety two only

Last Claimed Claimed against


Jan-17 2014-2017
LTA on block year
The travel vouchers are attached herewith. LTA will be taxable if the prescribed proof of travel and expense is not
attached

Date 9/18/2017 Signature


================================================================================
(For Internal Use only)

Approved By:

For HR:
Date:

For Finance:
Date:

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 should be for the shortest route to any place in India.

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