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/ ri!ing licence/Passport/"oter I / #adhaar/ other photo identity issued $y %tate/&entral go!ernment as a proof of identity and date of $irth. '. That I confirm that I am not in possession of an (P) connection from any *il &ompany for my domestic use+ neither in my name nor in name of any of my family mem$er ,ho are residing ,ith me. -. That I confirm that I am using (P) in a separate .itchen /. That I am a,are that same address also has a different household and for my domestic coo0ing my household is independent of other households or 0itchens if any ,ithin the same address. 1. That if any information/declaration gi!en $y me in this affida!it or any document su$mitted in support of identity/date of $irth/residence proof and eclaration on household shall $e found untrue or incorrect or false+ Indian *il &orporation ,ould $e ,ithin its rights to ,ithdra, the supply of )as/Terminate/sei2e the e3uipments & that I ,ould ha!e no claim+ ,hatsoe!er against the Indian *il &orporation for such ,ithdra,al/Termination/%ei2ure. I here$y !erify and confirm that ,hat has $een stated a$o!e is true to the $est of my 0no,ledge+ correct and nothing material has $een concealed there from. %olemnly affirmed and declared $y me this ___________ day of ____________

Signature of person making Declaration With name, Address, Consumer number and name of Distributor ------------------------------------------------------------------------------------------------------Declaration By Distributor Physically !erified the premises on ------------and found to $e independent household ,ith different .itchen in the address ---------------------------------------------------------------. *ther 4ouseholds ,here the connections are a!aila$le under the same address are not part of the household declared $y 5r. ------------------------------ as a$o!e. 6ame of Peron "isited: %ignature and %eal of istri$utor