Self Declaration

I ……………………………………… W/o Sh. …………………………………….……………………… R/o

………………………………………………………………..……………………………….…..……… do hereby
solemnly affirm and declare as under:-
1. That I am permanent resident of above said address.
2. That we are belong to BPL family.
3. That our ration card no. is ………………………..
4. That my name in Aadhar No. is ……………………….
5. That I have no other Gas connection in my name or any other family
member name of any company.
6. That I am eligible for Ujjawala Gas Connection Scheme.
7. That kindly issue me Gas Connection under Ujjawala Scheme.

Deponent
Verification:
Verified that above statement is true & correct to the best of my knowledge & belief,
nothing has been concealed there in.

Place: …………………… Deponent

Date: …………………………