Declaration for providing Gas Connection within Same address but Different Households

I _____________________Son/Daughter/Wife of____________________________
Resident of___________________________________________________________
affirm as under :-
1. That I am residing at_________________________________________________
_________________ & enclosing a copy of _______________ as proof of residence.
2. That I am also enclosing a copy of Pan card / Driving licence / Passport / Voter ID / Aadhaar / other photo identity issued by State / Central government as a proof of identity and date of birth.
4. That I confirm that I am not in possession of an LPG connection from 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.
5. That I confirm that I am using LPG in a separate Kitchen
6. That I am aware that same address also has a different household and for my domestic cooking my household is independent of other households or kitchens if any within the same address.
7. That if any information/declaration given by me in this affidavit or any document submitted in support of identity/date of birth/residence proof and Declaration on household shall be found untrue or incorrect or false, Indian Oil Corporation would be 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 stated above is true to the best of my knowledge, correct and nothing material has been concealed there from.
Solemnly affirmed and declared by me this ___________ day of ____________
Signature of person making Declaration With name, Address, Consumer number and name of Distributor
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Declaration By Distributor
Physically verified the premises on ------------and found to be independent household
with different Kitchen in the address
---------------------------------------------------------------. Other Households where the
connections are available under the same address are not part of the household
declared by Mr. ------------------------------ as above.
Name of Peron Visited:
Signature and Seal of Distributor