(To be attested by a Magistrate/Notary Public under his Official Seal)
AFFIDAVIT FOR CHANGE OF NAME - FROM SV HOLDER TO ANOTHER PERSON
(To be typed on non judicial stamp paper of appropriate value as applicable in the State of living)

From : Shri/Smt. __________________________S/o-W/o Shri/Smt. ____________________
Resident of ___________________________________________________________________
To : The Regional Manager,
Hindustan Petroleum Corporation Ltd.,
Dear Sir,
This is to advice that Shri/Smt. ____________________________________ who was residing at
______________________________________________________________________________
has left with me your equipment, covered under your subscription voucher no. ______________
dated _______________ issued by M/s __________________________________________
Since Shri/Smt. ______________________________ does not intend making use of the said
equipment, I request you that the same may be transferred in my name and a fresh consumer
number be given to me. Customer’s copy of the Subscription Voucher no. __________________ dated __________________ issued to Shri/Smt. ___________________________ is surrendered herewith. I confirm that I am agreeable to pay to the Corporation deposit for the equipment as per your terms currently in force.
I give below the consent from Shri/Smt. ___________________________ requesting Hindustan
Petroleum Corporation Ltd., to transfer his/her customership in my name and also authorizing me to sign the Termination Voucher and accept refund of deposit amount on his/her behalf.
Thanking you,
Yours faithfully,
(ACTUAL HOLDER OF THE EQUIPMENT)
Shri/Smt. ________________________ hereby confirm that I have no objection to the Corporation transferring the subject gas connection covered by Subscription Voucher no. _____________ dated ___________ held by me to Shri/Smt. ____________________________ and I hereby explicitly authorize M/s Hindustan Petroleum Corporation Ltd., to do so and to permit him/her to sign the TV as well as accept the refund of deposit on my behalf. I hereby totally surrender my claim on this gas connection and shall not have any claim whatsoever at any future date.
__________________________________
(SIGNATURE OF S. V. HOLDER)
(To be attested by a Magistrate/Notary Public under his Official Seal)