Self - Declaration for continuation of application under PMUY

1. Name of the Distributor: 2. Mobile No:

(where cleared application
Is available)

3. Name: 4. Aadhaar Number:

5. Spouse’s Name: 6. Father’s Name:

7. Address:

District:

State:

I declare that the details submitted earlier in my application remain un-changed. OR

I declare that my family composition has changed since I submitted my earlier application. The family
members given below are also staying with me at the afore-mentioned address.

I declare that none of the family members in my household have any LPG connection at the address mentioned.

Name of the beneficiary/ DOB as per

Sl Aadhaar No. Relationship Gender
Name of family members Aadhaar
FAMILY MEMBERS TO BE ADDED
1
2
3
4
FAMLY MEMBERS TO BE REMOVED (only in case of death, marriage).
Supporting certificate to be uploaded as per existing SOP.
1
2
3
4
I declare that I am willing to continue my application under Pradhan Mantri Ujjwala Yojana.

Date of Declaration Signature/ LTI of the Applicant

DISTRIBUTOR TO FILL

1. Earlier Application Number:

2. Application Date:

3. Sub - Category of Application: PMUY/ EPMUY/ EPMUY 2

I declare that I have kept the earlier application and have checked that it meets the SOP of EPMUY3.

Verified by distributor (Signature)