I _________ Son/Daughter/Wife of _________ resident of _________ affirm as under:
1. That I am an Indian National.
2. That I am residing at Above Address & enclosing a copy of Ration card/Electricity Bill/Rent Receipt/Rent Agreement/Phone Bill/LIC Policy/Flat Allotment Letter/House Registration paper as a residence proof.
3. That I am also enclose 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 _________ distributor in writing from change of address in his record.
5. That I confirm that I am not in possession of an LPG/PNG connection from any Oil Company for my domestic use. Neither in my name nor in my 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/PNG gas installation in the same kitchen.
8. That when second cylinder is issued 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, _________ would be within is right to withdraw the supply of gas/ Terminate/seize the equipments& that I would have no claim, whatsoever against the _________ for such withdrawal/Termination Seizure.
I hereby verify and confirm that what had 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 _________ date of _________.