Annexure – II

Pradhan Mantri Garib Kalyan Package

Declaration by PMUY Consumer

Confirmation of Refill Delivery

I, undersigned …………………………………………… son/daughter/wife/husband of ………………………… Age …….

Years residing at ………………………………………………… do hereby solemnly affirm and confirm that we have
received LPG refill under Pradhan Mantri Garib Kalyan Package for our connection under Pradhan
Mantri Ujjwala Yojna for consumer number _______________ from LPG Distributor of BPCL/HPCL/IOC
M/s. __________________________________ located at _______________________ on date _______ .
The delivery of refill has been accounted for in my DGCC and I have paid the amount of refill to the
person delivering the refill.

Signature of the customer

Date :
Place :

Annexure – II

Pradhan Mantri Garib Kalyan Package

Declaration by PMUY Consumer

Confirmation of Refill Delivery

I, undersigned …………………………………………… son/daughter/wife/husband of ………………………… Age …….

Years residing at ………………………………………………… do hereby solemnly affirm and confirm that we have
received LPG refill under Pradhan Mantri Garib Kalyan Package for our connection under Pradhan
Mantri Ujjwala Yojna for consumer number _______________ from LPG Distributor of BPCL/HPCL/IOC
M/s. __________________________________ located at _______________________ on date _______ .
The delivery of refill has been accounted for in my DGCC and I have paid the amount of refill to the
person delivering the refill.

Signature of the customer

Date :
Place :
Annexure I
Pradhan Mantri Garib Kalyan Package

Declaration by PMUY Consumer

Request for Counter Booking

I, undersigned, …………………………………………… Daughter / Wife of ………………………… Age ……. Years residing

at ………………………………………………… do hereby solemnly affirm and say as under :
1. That I am a resident of the above specified address. .
2. That I have availed connection under Pradhan Mantri Ujjwala Yojna in my name from LPG Distributor
of BPCL/HPCL/IOC M/s. _________________________________located at__ ______________________
and my consumer number is ____________________
3. That other than me, there are ___ members in my family who reside with me at the above specified
address.
4. That neither I nor any member of my family am/is in possession of a working Mobile number/phone.
Therefore cannot to do refill booing from registered mobile number

5. View above, I am requesting you to do counter refill booking for me.

Signature of the customer

Date :
Place :

Annexure I
Pradhan Mantri Garib Kalyan Package

Declaration by PMUY Consumer

Request for Counter Booking

I, undersigned, …………………………………………… Daughter / Wife of ………………………… Age ……. Years residing

at ………………………………………………… do hereby solemnly affirm and say as under :
1. That I am a resident of the above specified address. .

2. That I have availed connection under Pradhan Mantri Ujjwala Yojna in my name from LPG Distributor
of BPCL/HPCL/IOC M/s. _________________________________located at__ ______________________
and my consumer number is ____________________
3. That other than me, there are ___ members in my family who reside with me at the above specified
address.

4. That neither I nor any member of my family am/is in possession of a working Mobile number/phone.
Therefore cannot to do refill booing from registered mobile number

5. View above, I am requesting you to do counter refill booking for me.

Signature of the customer

Date :
Place :
Annexure IV
Pradhan Mantri Garib Kalyan Package

Declaration by PMUY Consumer

Request for Change in Mobile number

I, undersigned …………………………………………… Daughter / Wife of ………………………… Age ……. Years residing

at ………………………………………………… do hereby solemnly affirm and say as under :
5. That I am a resident of the above specified address. .

6. That I have availed connection under Pradhan Mantri Ujjwala Yojna in my name from LPG Distributor
of BPCL/HPCL/IOC M/s. __________________________________ located at

__________________________________ and my consumer number is ____________________

7. That other than me, there are ___ members in my family who reside with me at the above specified
address.

8. I wish to update the mobile number for registering against my LPG connection.

f. My existing mobile number is ;

g. this number is in the name of
h. My new mobile number is
i. This number is in the name of and
j. My relation with this person is

I also declare that the new number is not linked to any other LPG connection.

Signature of the customer

Date :
Place :
Document attached – Aadhaar of Consumer
 Salary Certificate
September 15, 2020

This is to certify that Mrs. Muthukumari V – 201903, is working with

our esteemed organization under the title of junior assistant since April 22,
2019. She is drawing the salary of Rs.4000/- every month.

We found this gentle lady fully committed to her job and totally
sincere toward this organization.

We are issuing this letter on the specific request of our employee

without accepting any liability on behalf of this letter of part of this letter.

Regards