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Affidavit for Loss of Subscription Voucher

I ______________________________________ Son/Wife/widow of Late ________________________________ aged _____ years an Indian Inliabitant Residing at _____________________________ do hereby affirm and state under oath as follows :1. That I am a consumer of HP Gas for Domestic use at the above address since _________. My Consumer Number is ____________. I was issued with subscription Voucher No. __________ Dated ____________ by M/s. Hindustan Petroleum Corporation Ltd. through HP Gas Distributors M/s. ___________________ towards gas Cylinder Deposit of Rs. _________ 2. That I am not able to produce the Subscription Voucher to obtain the Termination Voucher, as it is misplace/lost. 3. That I shall be liable to M/s. Hindustan Petroleum Corporation Limited or the Distributor for any loss or Expenses incurred by them if any one else produce the above referred subscription voucher to claim any amount or other benefit from M/s. Hindustan Petroleum Corporation Ltd. or their Distributors. Solemnly affirm by the within Named at Umreth on this day of February, 2013 ) Deponant ) signature Verification Verified that the contents of above para 1 to 3 are true and correct of the best of my knowledge and belief. I am liable u/s 193,199,200 of Cr.P.C./I.P.C. if any contents found false. Deponant


I, Mr./Mrs./Miss ______________________________________ aged ___ resident of ________________________________ Occupation _____________ hereby solemnly affirm oath below : 1. That My father had a HP Gas Connection from M/s _____________________________ vice Consumer No. __________ and subscription voucher (SV) No. ______ Dt.________. (Details may be obtained from distributor if the SV is lost) 2. That my ________________________________ has expired on ___________ 3. That I request M/s Hindustan Petroleum Corporation Ltd. to transfer the aforesaid connection in my name and allot me fresh consumer number. 4. That I indemnify M/s. Hindustan Petroleum corporation Ltd. and M/s. ________________________ from may future claims raised by anybody in respect of the above requested change of name in HP Gas connection. 5. That in the event of any claims whatever, raised by anybody against the transfer of above referred connection in may name, I shall immediately surrender the equipment issued to me in respect of the above request to M/s Hindustan Petroleum corporation Ltd. unconditionally. 6. That I also confirm that I or any member of my family, as detailed in my ration card, does not posses any LPG Connection from any Oil Company. 7. That the Original Subscription Voucher of ___________________________ is surrendered herewith. or 7. That the Original subscription Voucher of Shri/Smt./Ku. ____________________ ___________________is lost/Misplaced and is not traceable. if it to M/s Hindustan Petroleum Corporation Ltd. without using it anywhere for any purpose 8. That the Legal here of late _________________________________ Shah have appended their signature below expressing their no objection for the above requested of the HP Gas Connection. 9. That there are no more legal heirs of late Shri/Smt. / Ku. other than those appending their signature below Solemnly affirmed by the within named on the day of 20 at

Signatures We do not have any objection for tranferring the HP Gas connection from Late Shri/Smt/Ku. _____________________________________________________ to Late Shri/Smt./Ku. ___________________________________________ as requested above. Name Signatures 1. ______________________________________ 2.