MOBIL Version 1.0/11-14 Sr. No. Form 3 Mandate for Non-Aadhaar based LPG Subsidy Transfer (To be submitted to Bank) To, The Branch Manager, Name of Bank Name of Branch Sub: Authorization to update my LPG ID in the Bank Account for receiving LPG Subsidy through NEFT/NACH Thereby affirm that I have only one subsidized LPG connection, I also affirm that I do not possess an Aadhaar Number and confirm my choice to apt for payment of amounts due to me towards LPG Permanent Advance and Refill Subsidy through NEFT/NACH to my bank account, My 17 digit LPG ID for the purpose of seeding it against my Bank account is given below: PART A: LPG CONNECTION DETAILS (attach copy of Cash Memo or DGCC book or certificate from Distributor/OMC) LPG Consumer No. 17 agh PG ID (Dorr fil anything in 2) ‘Name exactly as it appears in LPG Connection (GN BLOCK LETTERS) Name of LPG Distributorship Consumer of BPCL/HPCL/TOCL available on your refill cash remo and on website www.MyLPG.in PART B: PARTICULARS OF MY BANK ACCOUNT Name exactly 6s isin the Bank Account (IN BLOCK LETTERS) First Name: idle Name Last Name Bank Name Branch Name IFSC Code* Bank Account Number Mobile Number ylola *hvallable in your cheque book or with your Branch Manager NOTE : Alll fields in Part A & B above are mandatory Thereby confirm that + The facts stated above are true and correct to best of my knowledge and belief. + Twill advise changes if any tothe Bank + Tunderstand that my bank account detells (neme, account, address/Aadhaar number) will be shared with BPCL/HPCL/TOCL for the purpose of transfer of LPG Subsidy into my above Bank account + Tfurther confirm that Ido not have Aadhaar number as on date. As soon as I receive the Rachaer number, I wl ink the same to ry above Bank account and LPG Consumer Number. + Thave attached a copy of Cash Memo/ blue boak/certificate from Disteibutor/OMC as a proof of my being an LPG consumer with this application + Talso understand that any false declaration attracts punishment under Indian Penal Code. Place Date: ____ Signature of the Consumer 3S ACKNOWLEDGEMENT SLIP Received Non Aadhaar Cash Transfer mandate ‘Form 3" from (Name), . ‘Account Number along with copy of Cash Memo/DGCC book/certificate from Distributor/OMC. Dati Sign & Stamp of Bank