I undersigned Mr./ Mrs. __________________________.

Son / Wife of
Mr. _______________________ Age ____ Years,
Resident Add- Of
-______________________________________________________________________

Desire to take Domestic LPG Connection in my name and giving residence address1. That I am an Indian Citizen.
2. That my date of birth is _______________ _(dd/mm/yy).
3. That neither nor other member of the household (household means a family
consisting of husband. wife." unmarried children and dependent parents living
together in a dwelling unit having common kitchen ) posses any LPG connection from
PSU Oil companies Natural Gas connection for domestion use in our dwelling unit.
4. That I am enclosing a copy of ration card including my name.
5. That 1 am enclosing the following Document
6.

a.__________________________' as a proof residence. (Ration Card)

b.____________________________as a proof of identity. (Aadhar (UI D), Passport,
Voter ID, Pan Card)

7. I confirm that the LPG connection issued to me will be used in my above

mentjoned address and For domestic cooking purpose only and shall abide by all
terms governing its use.
8. That I shall

not position any other LP Gas installation in the same kitchen.

9. That as and, when second cylinder is issued to me against this connection the
same will also be used in the same kitchen and with original installation.
10. That whenever I change my residence from present address to another. I will
inform M/s Wor1i Gas Company in writing in advance for change in the records.
11. That I am aware that the domest1c subsidized LPG connection as shall be
released by M/S Indian Oil Corporation/Hindustan petroleum corporation on the basis
of this affidavit and information submitted by me in the know your customer(KYC)
form. Proof of address and proof of identity shall later be subjected to deduplication check for the existence of any other domestic subsidized LPG connection
with any GOVT, Oil company. In my name or in the name of any other member of my
household as at para '3' above.
12. That if any information declaration given by me this declaration, The KYC from
or any document submitted in support of identity / residence proof shall be found
untrue or incorrect or false, than the concerned Oil company would be well within
its rights to withdraw the supply of gas / terminate the connection / forfeit the
security deposit and that I would have no claim whosoever against IOCL/BPCL/HPCL
for such withdrawal at termination / seizure / forfeiture.
I hereby declare that whatever has been stated above is true to the best of my
knowledge, correct and nothing material has been concealed there from
Date:: ___/ ___ /__

Name and Signature of person giving the declaration

Place:

(Name)-_____________________________