DBT. version LO/AE-14| sr No Form 3 Mandate for Non-Aadhaar based LPG Subsidy Transfer (To be submitted to Bank) Name of ranch ‘Sub: Authorization to update my LPG 1D in the snk Account for receiving LPG Sut {hereby affirm that Ihave only one subsidized LPG connection. I also affrm that I donot possess an Aachaar Number and confiem my choice to opt for payment of amounts due to me towards LPG Permanent Advance and Refil Subsidy through NEFT/HACH to my bank account. My 27 digit LPG ID forthe purpose of seeding it against my Bank account given below: dy through NEFT/NACH PART A: LPG CONNECTION DETAILS (attach copy of Cash Memo or DGCC book or certificate from Distributor/OMC) 17 6g 176 10" (ont i entng n=) Name exactly se appaar2 fn-acock TENS) Name of SpetmmPcitoc. “Avaliable on your ref ash memo and on website www MyLPG.in PART B: PARTICULARS OF MY BANK ACCOUNT. Name @xacty a5 15 9 (aN BLocK LETTERS) fez ame aie nae Las tae Bank Account Number bile Number +iola ‘avalabie in your cheque book or with your Branch Manager NOTE : All fields in Part A & B above are mandatory * Li ace changes if any othe Bank + Tunderstand that my bark account detals (name, account, adéress/Aadhaar number) wl be shared wth BPCL/MPCL/TOCL for the purpose of transfer of LPG Subsiy Into my atove Bank account ny above Bak account and LPG Consumer Number. «Ihave attached 3 copy of Cash Meme) Ble bock/cerifieats frm Distrbitar]OMC a8 poof of my being an L2G consumer with this appication. + Talso understand that any false declaration attracts punishment under Indian Penal Code. Pace: bate: Signature of the Consumer [ACKNOWLEDGEMENT SLIP Received Non Aaghaar Cash Transfer mandate ‘Frm 3'from (Name), ‘count Number ‘slong with copy of Cash Memo/ DSCC book/cetificte from Distributor/OMC. In & Stamp of Bank