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 citizen2 That my date of
birth is(LPG connection cannot be provided toa 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 unit4. That I am enclosing a copy
Ration card number including my nameOr& 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 documentsa .as a proof residenceb. 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 JOCL1 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.
