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I ______________________________________ Son/Wife/widow of Late ________________________________ aged _____ years an Indian Inliabitant Residing at _____________________________ do hereby affirm and state under oath as follows :1. That I am a consumer of HP Gas for Domestic use at the above address since _________. My Consumer Number is ____________. I was issued with subscription Voucher No. __________ Dated ____________ by M/s. Hindustan Petroleum Corporation Ltd. through HP Gas Distributors M/s. ___________________ towards gas Cylinder Deposit of Rs. _________ 2. That I am not able to produce the Subscription Voucher to obtain the Termination Voucher, as it is misplace/lost. 3. That I shall be liable to M/s. Hindustan Petroleum Corporation Limited or the Distributor for any loss or Expenses incurred by them if any one else produce the above referred subscription voucher to claim any amount or other benefit from M/s. Hindustan Petroleum Corporation Ltd. or their Distributors. Solemnly affirm by the within Named at Umreth on this day of February, 2013 ) Deponant ) signature Verification Verified that the contents of above para 1 to 3 are true and correct of the best of my knowledge and belief. I am liable u/s 193,199,200 of Cr.P.C./I.P.C. if any contents found false. Deponant
Signatures We do not have any objection for tranferring the HP Gas connection from Late Shri/Smt/Ku. _____________________________________________________ to Late Shri/Smt./Ku. ___________________________________________ as requested above. Name Signatures 1. ______________________________________ 2.