To be printed to Rs 20/- non judicial stamp paper

AFFIDAVIT

I __________________________, s/o ___________________________, r/o

____________________________________
______________________________________________________________________, affirm
as under:

1. That I am an Indian national.

2. That I am residing at
_________________________________________________________________________
3. ____________________________________________________________________________________
4. That I am also enclosing a copy of rent agreement paper as a residence proof.
5. That I am also enclosing a copy of pan card issued by central government as proof of
identity and date of birth.
6. That whenever I change my residence from present address to another, I will inform my
indane distributor in writing for change of address in his record.
7. That I confirm that I am not in possession of an LPG connection from any oil company
for my domestic use. Neither in my name nor in name of any of my family member who
are residing with me.
8. That I confirm that the LPG connection issued to me will be used in my above
mentioned address only.
9. That I shall not position any other LPG gas installation in the same kitchen.
10. That when second cylinder is issued to me I will use the same in the same kitchen on the
original installations only.
11. That if any information/declaration given by me in this affidavit or any document
submitted in support of identity/date of birth/residence proof shall be found untrue or
incorrect or false, Indian Oil Corporation would be wihin the rights to withdraw the
supply of Gas/terminate/seige the equipments & that I would have no claim, whatsoever
against the Indian Oil Corporation for such withdrawal/Termination/Seizure.

I hereby verify and confirm that what has been stated above is true to the best of my knowledge,
correct and nothing material has been concealed therefrom. Solemnly affirmed and declared
before me this ____ day of ______.

Signature & seal of Signature of person make

Notary Public affidavit