UNDERTAKING FOR LOSS OF LPG PRESSURE REGULATOR/CYLINDER

I, _________________________________ son/daughter/wife of Shri _____________________ aged _____ years, Resident of ____________________________________________________ and Indian inhabitant do hereby solemnly affirm and declare as follows: 1. That I am a consumer of HPGAS with Customer No. __________ being served through their distributor M/s. ________________________________________ since ________. 2. That I have lost the LPG Pressure Regulator/Cylinder on ____________ (date), involving _________________________________________________________(reasons for loss). 3. That I have neither given the pressure regulator / cylinder to any other person nor used it for any purpose against the guidelines issued by HPCL. 4. That I shall be liable to any action taken by M/s. HPCL in case this claim for loss of Pressure Regulator/cylinder is proved to be false, or it is found that I am involved in illegal use of the pressure regulator/cylinder. 5. That I undertake to return forth with the above referred pressure regulator/cylinder to M/s. Hindustan Petroleum Corporation Ltd., if found at any time.

SIGNED Place: Dated:

________________________ (Signature of the Customer)

IN THE PRESENCE OF: 1. ____________________ 2. ____________________