20RS KE PAPER PAR HO GA ES PAR NAHI NONO NO
TO BE RS 20/-NON-JUDICIAL STAMPONLY
I Son/Daughter/Wife of
Affirm as under:-
1. That I am an Indian national.
2. That I am residing at
& enclosing a copy of Ration card/Electricity bill/Rant receipt/
LIC policy/Flat allotment letter/House registration paper as a residence proof .
3. That I am also enclosing a copy of Pan card/Driving license/Passport/voter ID/
Other photo identity issued by State/Central government as a proof of identity &
date of birth .
4. That whenever I change my residence from present address to another, I will inform
my Indene distributor in writing for change of address in his record.
5. That I confirm that I am not in possession of an LPG connection form 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 .
6. That I confirm that the LPG connection issued to me will be used in my above
mentioned address only.
7. That I shall not position any other LPG gas installations in the same kitchen .
8. That when second cylinder is sued to me I will use the same in the same kitchen on
The original installations only .
9. 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 by within its rights to withdraw
the supply of Gas/Terminate/seize 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 staled...