MOBTL Version 1.0/11-14 Sr N Form 3 Mandate for Non-Aadhaar based LPG Subsidy Transfer (To be submitted to Bank) 10, ‘The Branch Manager, Name of Bank Name of Branch ‘Sub: Authorization to update my LPG ID in the Bank Account for receiving LPG Subsidy through NEFT/NACH Thereby affirm that I have only one subsidized LPG connection. I also affirm that I do not possess an Aadhaar Number and confirm my choice to opt for payment of amounts due to me towards LPG Permanent Advance and Refill Subsidy through NEFT/NACH to my bank account. My 17 digit LPG ID for the purpose of seeding It against my Bank account is given below: PART A: LPG CONNECTION DETAILS (attach copy of Cash Memo or DGCC book or certificate from Distributor /OMC) LPG Consumer No 17 digit PG 10 (Gon fil anything in x) Name exactly as it appears in LPG Connection (GN BLOCK LETTERS) Name of LPG Distributorship Consumer of BPCL/HPCL/TOCL, available on your refill cash memo and on website www.MyLPG.in PART B: PARTICULARS OF MY BANK ACCOUNT Name exactly asit isin the Bank Account (IN BLOCK LETTERS) Fest Name Middle Name Last Name. Bank Name Branch Name IFSC Code* Bank Account Number Mobile Number eral *Avallable in your cheque book or with your Branch Manager NOTE : All fields in Part A & B above are mandatory Thereby confirm that: «+ The facts stated above are true and ci + T will avise changes if any to the Bank. + Tunderstand that my bank account details (name, account, address/Aadhaar number) will be shared with BPCI/HPCL/IOCL for the purpose of transfer of LPG Subsidy into my above Bank account. ‘* Tfurther confirm that I do not have Aadhaar number as on date, As soon as I receive the Aadhaar number, I will lnk the same to ‘my above Bank account and LPG Consumer Number. «+ Thave attached a copy of Cash Memo/ blue book/certficate from Distributor/OMC as a proof of my being an LPG consumer with this application “+ Talso understand that any false declaration attracts punishment under Indian Penal Code, rect to best of my knowledge and belief Place: Date: Signature of the Consumer 3< ACKNOWLEDGEMENT SLIP Received Non Aadhaar Cash Transfer mandate ‘Form 3’ from (Name) . ‘Account Number along with copy of Cash Mema/ DGC book/certificate from Distributar/OMC. Date: Sign & Stamp of Bank.