AFFIDAVIT ON LOSS OF T.

V
(ON RS.15/- COURT FEE STAMP PAPER)

I _____________________________ aged _________________________ years an

Indian inhabitant residing at __________________________________________ do
solemnly affirm and state as under: -

1. That I had an Indane gas installation at

___________________________________________________________(full
address) in my name and my consumer number was _________________,
2. That I returned the gas cylinder(s) and regulator to Indian Oil Corporation
Ltd. /Indane Distributor M/s ______________________________________
______________ on ____________________________________________
____________ (date & reason).
3. That Indian Oil Corporation Ltd./the said distributor M/s ________________
_______________ refunded me deposit of Rs._________________________
___( ) paid by me towards the cylinder(s) and regulator and
issued me the Termination Voucher No.___________________________
dated ___________________.
4. That the referred Termination Voucher has been lost by me.
5. That I have on availed of any LPG connection in my name at any place in
India either from Indian oil corporation Ltd., of from any other gas marketing
company in Indian by using the above referred Termination Voucher.
6. That I undertake to return forthwith the above referred Termination Voucher
to Indian Oil Corporation Ltd., Bombay = 400034 if found at any time in
future.

Solemnly affirm by the within named _________________________________________

at _________________________ on this __________________ day of ______________
____________ 199 before me.

ATTESTED BY DEPONENT

JUDICIAL MAGISTRATE/NOTARY PUBLIC