Loss of Subscription Voucher

I T.Shankrappa. son/daughter of Basappa.S.Talawar. Aged. 48 Years on

Indian inhabitant residing at(full residential address) do Shankrappa
Basappa.Talawar. Honyal Galli Nr Raghavendra Temple Killa Bagalkot
. solemnly affirm and state as follower :
1. That I am a consumer of HP Gas for domestic use since 09 Years. my
Consumer Number is 610603 I was issue with Subscription Voucher
No1003864 .dated 19-11-2001. by M/s. Kosen Gas Co./ Hindustan
petroleum Corporation limited. Gas Dealers M/s Veerabhadreshwar Gas
Centre Opp Bus Stand Bagalkot towards a Gas cylinder and a
regulator on loan for my use against the refundable deposit of Rs1000/-
2. That I was given the Gas cylinder and regulator when I was residing at
( old address ) There after I shifted to above mentioned address
residence.
3. That I want to return the Subscription Voucher along with the cylinder and
regulator an I am shifting my residence from this town and want to
terminate the agreement with the above mentioned company.
4. That I am not-able to produce the subscription Voucher along with the
cylinder and regulator to obtain the refundable deposit an it is misplaced
/lost.
5. That I have not assigned or transferred the subscription Voucher to any
person whomsoever.
6. That I undertake to return forthwith the above referred subscription
Voucher to M/s Hindustan Petroleum corporation Limited. Hindustan
Bhawan, & Swoorji Vallabhdas Marg Bombay-400038 if found at any time
in the future.
7. That I shall be liable to M/s Hindustan Petroleum corporation Limited.
Bombay for any loss or expend incurred by them is any one else produces
the above referred subscription Voucher to claim any amount from the
company or their gas dealer.

Solemnly affirm by the within named … … … … … … … … … … … … … … …

… …
………………………………………………………………………………………………………
……. at……………….On this……………………….day of …………………………… …
… … … … … …… ………19……….month

Signature of the Deponent

 Loss of Subscription Voucher

I.------------------ . son/daughter of ---------------------. aged .years on Indian inhabitant

residing at ( full residential address) do---------------------- solemnly affirm and state
as follower :
8. That I am a consumer of HP Gas for domestic use since. my consumer Number is
I was issue with subscription voucher No dated by M/s. Kosen Gas Co./
Hindustan petroleum Corporation limited. Gas Dealers M/s-------------------- towards
a Gas cylinder and a regulator on loan for my use against the refundable deposit
of Rs ------
9. That I was given the Gas cylinder and regulator when I was residing at ( old
address ) There after I shifted to above mentioned address residence.
10.That I want to return the Subscription Voucher along with the cylinder and
regulator an I am shifting my residence from this town and want to terminate the
agreement with the above mentioned company.
11.That I am not-able to produce the subscription Voucher along with the cylinder
and regulator to obtain the refundable deposit an it is misplaced /lost.
12.That I have not assigned or transferred the subscription Voucher to any person
whomsoever.

Cont….2
13.That I undertake to return forthwith the above referred subscription Voucher to
M/s Hindustan Petroleum corporation Limited. Hindustan Bhawan, & Swoorji
Vallabhdas Marg Bombay-400038 if found at any time in the future.
14.That I shall be liable to M/s Hindustan Petroleum corporation Limited. Bombay for
any loss or expend incurred by them is any one else produces the above referred
subscription Voucher to claim any amount from the company or their gas dealer.

Solemnly affirm by the within named … … … … … … … … … … … … … … … … …

…………………………………………………………………………………………………………….
at……………….On this……………………….day of …………………………… … … … … … …
…… ………19……….month

Signature of the Deponent

Loss of subscription Voucher

1…………………………………….son/daughter of shri.………………………… …………….
…………………………aged ………….years on Indian inhabitant residing at ( full
residential address)…………………………………………… do solemnly affirm and state
as follower :
15.That I am a consumer of HP Gas for domestic use since………my consumer
Number is………… I was issue with subscription voucher No………………dated
………….by M/s. Kosen Gas Co./ Hindustan petroleum Corporation limited. Gas
Dealers M/s …………………………… … … … … …………………………………………….
towards a Gas cylinder and a regulator on loan for my use against the refundable
deposit of Rs …………….
16.That I was given the Gas cylinder and regulator when I was residing at ( old
address ) …… … … … … … … … …… … … ……There after I shifted to above
mentioned address residence.
17.That I want to return the Subscription Voucher along with the cylinder and
regulator an I am shifting my residence from this town and want to terminate the
agreement with the above mentioned company.
18.That I am not-able to produce the subscription Voucher along with the cylinder
and regulator to obtain the refundable deposit an it is misplaced /lost.
19.That I have not assigned or transferred the subscription Voucher to any person
whomsoever.
20.That I undertake to return forthwith the above referred subscription Voucher to
M/s Hindustan Petroleum corporation Limited. Hindustan Bhawan, & Swoorji
Vallabhdas Marg Bombay-400038 if found at any time in the future.
21.That I shall be liable to M/s Hindustan Petroleum corporation Limited. Bombay for
any loss or expend incurred by them is any one else produces the above referred
subscription Voucher to claim any amount from the company or their gas dealer.

Solemnly affirm by the within named … … … … … … … … … … … … … … … … …

…………………………………………………………………………………………………………….
at……………….On this……………………….day of …………………………… … … … … … …
…… ………19……….month

Signature of the Deponent