AFFIDAVIT I ...S/o, D/o/W.o..resident of do hereby solemnly affirm on oath as under: 1. That I am an Indian National. 2.

. That I possess/do not possess Ration Card in my name issued by Local Food & Civil Supplies Department. 3. That I am permanently residing at & enclosing a copy of Ration Card/Voter Card/Electricity Bill/Rent Receipt/Employers Letter/LIC Policy/Flat Allotment Letter/House Registration Paper as a resident proof. 4. That I am also enclosing a copy of PAN Card/Driving License/Passport/Voter ID/Other Photo Identity issued by State / Central Government as a proof of identity & Date of Birth. 5. That I conform that I am NOT in possession of LPG Connection from any Oil Company for my domestic use Neither in my name nor in name of any of my family members who are residing with us. 6. That I will NOT use this domestic connection for commercial usage, in vehicles or for any purpose other that cooking food in my kitchen/house. If found, some may be confiscated by concerned authority. 7. That I confirm that the LPG connection issued to me will be used in my above mentioned address only. 8. That whenever I change my residence from present address to another, I will inform my Indane distributor in writing for change of address in his record. 9. That I shall not position any other LPG installation in the same kitchen. 10. That when second cylinder is issued to me I will use same in the same kitchen on the original installations only & I will never exchange my cylinders & regulator with anybody. 11. That if any information/declaration given by me in this affidavit or any document submitted in support of identity/date of birth/residence proof shall be found incorrect or false , Indian oil Corporation would be within its right to withdraw the supply of Gas/Terminate/Seize the equipment & that I would have no claim, whatsoever against the Indian Oil Corporation/LPG Distributor for such withdraw Termination/Seizure. Verification: Deponent I the above named deponent further solemnly affirm and declare that the above statement is true and correct to the best of my knowledge and belief and nothing has been concealed therein. Date: Place: Deponent