ANNEXTURE-A

Format for Declaration/Notarized Affidavit

(To be submitted by person desirous of new LPG onnection or connection a!ainst Termination "ouc#ers$ %ation card#older to submit t#is declaration on plain paper& ot#ers to submit in t#e form of notarized affidavit on non'(udicial stamp paper of re)uisite value$* Declaration I Resident of desire to take domestic LPG connection in my name and affirm as under: 1. T at I am an Indian citi!en. ". T at my date of #irt is $LPG connection cannot #e %ro&ided to a %erson under 1' years of a(e) *. T at neit er I+ nor any ot er mem#er of t e ouse o,d $ ouse o,d means : fami,y consistin( of us#and+-ife+unmarried c i,dren and de%endent %arents ,i&in( to(et er in a d-e,,in( unit a&in( common kitc en)+%ossess any LPG connection from P.U /i, 0om%anies or Pi%ed Natura, Gas connection+ for domestic use. 1. 2 T at I am enc,osin( a co%y Ration card num#er ----------------- inc,udin( my name. +r 2 T at do not a&e Ration card in my name or in t e name of any mem#er of my fami,y as defined a#o&e. 2 3e,ete+ - ic e&er is not a%%,ica#,e. 4. T at I am enc,osin( t e fo,,o-in( documents a. ------------------- as a %roof residence #. ------------------- as %roof of identity. 5. I confirm t at t e LPG connection issued to me -i,, #e used in my a#o&e mentioned address and for domestic cookin( %ur%ose on,y and I s a,, a#ide #y a,, terms (o&ernin( its use. 6. T at I s a,, not %osition any ot er LPG Insta,,ation in t e same kitc en. '. T at as and - en second cy,inder is issued to me a(ainst t is connection t e same -i,, a,so #e used in t e same kitc en and -it t e ori(ina, insta,,ation. 7. T at - ene&er I c an(e my residence from %resent address to anot er+ I -i,, inform t e 89s Tec no,o(y 0o-/%. .tore Ltd.+ : ara(%ur-" in -ritin( in ad&ance for c an(e of address in t e records. 1;. T at if any information 9 dec,aration (i&en #y me in t is undertakin( or any document su#mitted in su%%ort of identity9residence %roof s a,, #e found untrue or incorrect or fa,se+ Indian /i, 0or%oration9< arat Petro,eum 0or%oration9=industan Petro,eum 0or%oration -ou,d #e -it in its ri( t to -it dra- t e su%%,y of Gas9Terminate t e connection9sei!e t e e>ui%ment9forfeit t e security de%osit and t at I -ou,d a&e no c,aim+ - atsoe&er a(ainst Indian /i, 0or%oration9< arat Petro,eum 0or%oration9 =industan Petro,eum 0or%oration for suc -it dra-a,9Termination9.ei!ure9forfeit. I ere#y dec,are t at - ate&er as #een stated a#o&e is true to t e #est of my kno-,ed(e+ correct and not in( materia, as #een concea,ed t ere from.
3ate: P,ace: .i(nature of %erson (i&in( t e 3ec,aration9Affida&it Name: -----------------------------------------------------