Format for Declaration/Notarized Affidavit

( To the admitted by persons desirous of new LPG connection against Termination voucher
km I on cardholder 10 admit this declaration on plain paper, ethers to submit in the form of
notarized affidavit on non-judicial stamp paper of requisite vaster
Declaration
I Son Daughter wife of. Age..year
(desire to take domestic LPG connection my name and affirm as under:-
1, That I am an Indian citizen
2 That my date of birth is (LPG connection cannot be provided to
a person under Shears of age)
3. Thai neither J, nor any other member of the household/household means a family
consisting of husband wife, unmarried children and dependent parents Irving together in a
dwelling unit having common kitchen), possess any LPG connection from PSV oil
Companies or piped Natural Gas connection, for domestic use in our dwelling unit
4. That I am enclosing a copy Ration card number including my name
Or
& That ] do not have nation Card in my name or in the name of any member of my household
as Joined above. As and when a raison card IS issued m my name or in the name of any of
the members of the "household the same shall be produced to the oil company LPG
distributor for up-dating records
% Delete, whichever is not applicable
. Thai J am enclosing the following documents
a . as a proof residence
b. as proof of identity.
6 I confirm that the LPG connector issued to me will be used in my above-mentioned address
and for domestic cooking purpose only and I shall abide by ail terms governing its use.
7. That I shall nor position any other LP gas installations in the same kitchen.
8. that as and when second cylinder is issued to me against this connection the same will be
also be used in the same kitchen and with the original installation.
9. That wherever J change my residence from present address to another. I will inform
M/s..
Name of distributors RGGLC) inwriting in advanced for change of address the records.
JO. That / am aware that the domestic subsidiz'd LPG connection as shall be released y hi
In&an ok corporation (HPCL) on the bar.c of this affjbrrj. and Information submitted by me in
the know your Customer(KYQ form Proof of address and proof of identity, shall later be
subjected to de-duplication check for existence of any other demesne bridged LPG
connection with any Govt. Oil company, m my name Cl in ike name of any other member of
my household' as as Para '
,
above.
11 That if any information declaration given by me in this undertaking, the KTCfbrm or any
document submitted in support cfi&mtity residence proof shall be found unirue incorrect or
false, the oil. company would be within its rights to wifkdmv the supply of Gas Terminate the .
connection sei&3 the equipments forfeit the security deposit and that I would have no claim,
whatsoever4 against JOCL
1
BPCL HPCL for such with dranxil-Termin anon Setizin?
forfeiture
hereby declare that whatever has been started above is true to the test of my k ^ledge,
correct and nothing material has been concealed there form.