Format for Declaration (To be submitted by persons desirous of New LPG Connection or connection against Termination Voucher)

Declaration

I________________________________ son/daughter/wife of ___________ Age _______years, resident

of____________________________________________________________________________________________

_____________________________________________________________________ desire to take domestic LPG

connection in my name and affirm as under:

1. That I am an Indian citizen/Non Resident Indian /Staff of Foreign nationality serving in India/ Foreign national

residing in India under valid visa / person returning to India on transfer of residence basis/ PIO

*Tick whichever is applicable. Only Indian citizens are eligible for subsidized LPG.

2. That my date of birth is __________ (LPG connection cannot be provided to a person under 18 years of age)

3. That neither I, nor any other member of the household (household means a family consisting of husband,

wife, unmarried children and dependent parents living together in a dwelling unit having common kitchen),

possess any LPG connection from PSU Oil Companies or Piped Natural Gas Connection for domestic use in our

dwelling unit. (‘Households’ having Piped Natural Gas connection are not entitled for Subsidized LPG)

4. @That I am enclosing a copy of Ration card number ___________________including my name

Or

@That I do not have Ration Card in my name of in the name of any member of my ’household’ as defined

above. As and when a ration card is issued in my name or in the name of any of the members of the

‘household’, the same shall be produced to Oil Company LPG distributor for updating records.

@Delete, whichever is not applicable

5. That I am enclosing the KYC form duly filled in along with the Proof of Address (POA) and Proof of Identity(POI)

6. I confirm that the LPG connection issued to me will be used in my above mentioned address and for domestic

cooking purpose only and I shall abide by all terms governing its use.

7. That I shall not position any other LP gas installations in the same kitchen

8. That as and when second cylinder is issued to me against this connection the same will also be used in the

same kitchen and with the original installation.

9. That whenever I change my residence from present address to another, I will inform M/s.

_________________________________ (Name of Distributors/RGGLV) in writing in advance for change of

address in the records.

10. That I am aware that the domestic subsidized LPG connection as shall be released by M/s. Indian Oil

Corporation (IOCL) / Bharat Petroleum Corporation (BPCL) / Hindustan Petroleum Corporation (HPCL) on the

basis of this declaration and information submitted by me in the Know Your Customer (KYC) form, Proof of

Address and Proof of Identity, shall later be subjected to de-duplication check for existence of any other

domestic subsidized LPG connection with any govt. Oil Company, in my name or in the name of any other

member of my ‘household’ as at para ‘3’ above.

11. That if any information / declaration given by me in this undertaking, the “KYC’ form or any document

submitted in support of identity / residence proof shall be found untrue or incorrect or false, the Oil Company

would be within its rights to withdraw the supply of Gas/Terminate the connection/ seize the equipments /

forfeit the security deposit and that I would have no claim whatsoever against IOCL/ BPCL/ HPCL for such

withdrawal / Termination / Seizure / Forfeiture.

I hereby declare that whatever has been stated above is true to the best of my knowledge, correct and nothing

material has been concealed there from.

Date :_______________ Signature of person giving the Declaration

Place :_______________ Name :____________________________________

NC-TV Declaration format Ver.1-BPC/14

Know Your Customer(KYC) Form

(To be filled in black ink with BLOCK LETTERS. Fields marked with * are mandatory) ( For Instructions to fill form please see overleaf)

1) Personal Details Paste your photo here

(Mr./Mrs./Ms) *

First Name*

Middle Name

Last name*

b) Gas Consumer Number* c) Date of Birth*

D D M M Y Y Y Y

d) Close Relative

2) Address for LPG connection / Contact Information Proof of Address ( POA) category Code* P O A

House/ Flat #, Name* Floor No*

Housing Complex/Building Land Mark

Street/Road Name

City/Town/Village * Pin Code*

District *

State*

Phone #* : Mobile No Landline #

Email id

3) Other Relevant Details

a) Proof of Identity (POI)

POI Category Code* P O I

Card Number*

b) Ration Card Details if Available State Of Issue

Ration Card Number

Declaration: I hereby declare that the information provided by me above is true and correct to the best of my knowledge and

belief. I also confirm that in the event of any information provided by me is found incorrect / is incomplete and also in the event

of any violation of Government Regulation related to the supply and distribution of LPG, IOC/BPC/HPC will be within its right to

discontinue supply of LPG cylinders to me, forfeit of security deposit and levy of penal charges as per the policy and guidelines

and may initiate legal action applicable under provisions.

Name & Signature of Applicant * Date:-_______________________________________________________________________________________________________

To be filled by Distributor

I confirm having verified the photocopies of documents above against their originals. Consumer Number (If allotted):

Signature of Distributor Date: Name of Distributorship with SAP Code -----------------------------------------------------------------------Tear Off -----------------------------------------------------------------------------

Acknowledgement I/We, hereby, confirm receipt of duly filled in KYC form along with copy relevant POI, POA documents from Name _______________________________Consumer no (if applicable)_________________ on______________

Signature and Seal of Distributor

Father’s /Spouse Name*

Mother’s name*

Form KYC Version 3 - 2014-BPC

Instructions for Filling KYC Form

Fields marked with * are mandatory and must be filled in by person submitting KYC

1 a) Name Name to be entered as given in Photo ID Proof

1 b) Gas Consumer Number

Mandatory for consumers already using LPG from IOC/BPC/HPC

1 c) Date of Birth Mandatory to provide Date of Birth

1 d) Details of Close Relative

Father or Spouse and Mother’s name is mandatory. Please strike off whichever is not applicable.

2 Proof Of Address ( POA)

At least copy of one of the documents listed below should be attached and category mentioned in the form. The Address to be entered against the relevant fields exactly as it appears in the POA. Person submitting KYC is required to produce the original of document for verification by the distributor.

List of documents Category Code Aadhaar (UID) POA01

Driving License POA02

Lease agreement POA03

Voter ID POA04

Telephone/Electricity /Water bill POA05

Passport POA06

Self-declaration attested by a Gazetted officer. POA07

Ration Card POA08

Flat allotment/possession letter POA09

House registration document POA10

LIC Policy POA11

Bank/Credit Card Statement POA12

3 a) Proof of Identity (POI)

At least copy of one of the documents listed below should be attached and category mentioned in the form. Consumer is required to produce the original of the document for verification by the distributor. List of documents Category Code Aadhaar Number (UID) POI01

Passport Number POI02

PAN Card Number POI03

Voter ID Card POI04

ID card Issued By Central/State POI05

Driving License POI06

मैकननक की ज ॉच ररऩोर्ट 1. आवेदक क न म …………………………………………………………2. आवेदक क न म ऩूर ऩत (ऱेंड सहित यहद कोई िै ) ……………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

3. आवेदक के घर ज ॉच के दौर न उऩऱब्ध व्यक्तत क न म व आवेदक से सॊबॊध……………………………………………………………………………………………………………………………

4. तय आवेदक उऩरोतत ऩत ेऩर रित िै ह ाँ/नह ीं5. तय आवेदक के ऩ स अऩनी अऱग से रसोई िै ह ाँ/नह ीं6. तय आवेदक के रसोई में ऩिऱे से कोई गैस कन्नेतशन िै ह ाँ/नह ीं7. तय रसोई में ननम्न वस्तुए उऩऱब्ध िै (क) फ्रिज ह ाँ/नह ीं(ख) हिर्र ह ाँ/नह ीं(ग) ऩूज स्थऱ ह ाँ/नह ीं(घ) गैस स्र्ोव रखने के लऱए उऩयुतत सैल्फ़ (shelf) ह ाँ/नह ीं(ड) उऩयुतत बेक्न्र्ऱेशन ह ाँ/नह ीं8. तय उऩरोतत ऩत ेऩर ऩिऱे से कोई गैस कन्नेतशन िै तो दश टए :-

उऩभोतत क न म आवेदक के स थ सम्बन्ध ग्र िक सॊख्य ववतरक क न म

9. तय रसोई एऱ.ऩी.जी. इस्तेम ऱ िेत ुसुरक्षित िै ह ाँ/नह ींयहद नि ॊ तो वववरण दें ……………………………………………………………………………10. तय आवेदक के ऩ स आई. एस. आई. म कट गैस स्र्ोव िै ह ाँ/नह ींयहद ि ॉ तो ब् ॊड क न म दश टए ……………………………………………………………………11. तय उऩऱब्ध चऱु आई. एस. आई म कट िै व रसोई में इस्तेम ऱ करने िेत ु ह ाँ/नह ींसुरक्षित क्स्थनत में िै

ववतरक क न म ……………………………………... मैकननक क न म व िस्त िर ज ॉच करने की त र ख …………………………………... हदन ॊक …………………………

मैकननक की ज ॉच ररऩोर्ट

7. तय रसोई में ननम्न वस्तुए उऩऱब्ध िै

Connection Instalation FormatDeclaration for NC or TV-FormatDeclaration issue gas Connection FormatDeclaration issue gas Connection Format2KYC Format BPCMECHANIC INSPECTION FORMAT