Annexure D FORMAT FOR AFFIDAVIT

To, M/s ( Name of OMC)

Dear Sirs, I Mr. / Mrs. son/daughter/wife of Mr . aged . years, residing at .. hereby solemnly affirm as under: That my ____________________(relation with the connection holder) was in possession of LPG connection from M/s _____________________________(name of distributor of OMC) vide SV no._____________dated_____________Consumer No. _______________. That Shri/ Smt____________________________________ has passed away on __________________. Attested copy of the death certificate is enclosed. That I being the ___________________(relation of the next of kin) request that the LPG connection may be transferred in my name. I confirm that I am agreeable to submit the documents required for the same and to pay the deposit for the equipment as per your terms. I hereby undertake to indemnify M/s IOC/BPC/HPC against any claim by any other person at a later date with regard to the transfer of the said LPG connection in my name.

SIGNATURE NAME Date: Place: