AFFIDAVIT

TO WHOMSOEVER IT MAY CONCERN

I______________________________S/o / D/o / W/o ____________________________

R/o Village__________________Block__________________District__________________

Declare and undertake as follows:

1. That the applicant has approached HPStCB/CSC-SPV. for allotment of the CSC (Lok Mitra
Kendra) at Panchayat_____________________, Village________________,
Block_____________, District___________________________
2. That HPStCB/CSC-SPV has agreed to allot the CSC/LMK as per terms and conditions of the
VLE agreement being signed separately and the CSC/LMK shall be operated only at the place
of allotment and as per the terms of the said VLE agreement.
3. That there is no CSC/LMK existing within the Panchayat the location where I wish to setup
and operate my CSC/LMK or Panchayat has no objection to set up more than one CSC/LMK.
4. That the information given above by me is correct and if my Declaration given in this
undertaking is found incorrect, HPStCB/CSC-SPV shall have full right to summarily cancel my
CSC/LMK without giving any further opportunity.
5. That if my CSC/LMK is cancelled as per terms of this undertaking, I shall have no right to any
claim towards HPStCB/CSC-SPV, including compensation for setting up of the CSC/LMK or
Refund of any payment made to the HPStCB/CSC-SPV towards allotment of CSC/LMK or
charges for services, etc.
6. That if my CSC/LMK is cancelled the HPStCB/CSC-SPV will only be liable for amount
pertaining to my current account in HPStCB/CSC-SPV That if HPStCB/CSC-SPV agrees to
allocate me CSC/LMK, I will open my current account in HPStCB/CSC-SPV and will use the
same for G2C service transaction from LMK portal.
7. That if HPStCB/CSC-SPV agrees to allocate me CSC/LMK, I will open my current account in
HPStCB and will use the same for G2C service transaction from LMK portal.
8. That I surrender all my rights to appeal in any court or a forum in India if my CSC is
cancelled as per terms of this undertaking.

Witness:
Name : _ Signature