(To be attested by a Magistrate/Notary Public under his Official Seal)

AFFIDAVIT FOR CHANGE OF NAME - FROM SV HOLDER TO ANOTHER PERSON

(To be typed on non judicial stamp paper of appropriate value as applicable in the State of living)

From : Shri/Smt. __________________________S/o-W/o Shri/Smt. ____________________

Resident of ___________________________________________________________________

To : The Regional Manager,

Hindustan Petroleum Corporation Ltd.,

Dear Sir,

This is to advice that Shri/Smt. ____________________________________ who was residing at

______________________________________________________________________________
has left with me your equipment, covered under your subscription voucher no. ______________
dated _______________ issued by M/s __________________________________________

Since Shri/Smt. ______________________________ does not intend making use of the said
equipment, I request you that the same may be transferred in my name and a fresh consumer
number be given to me. Customer’s copy of the Subscription Voucher no. __________________
dated __________________ issued to Shri/Smt. ___________________________ is surrendered
herewith. I confirm that I am agreeable to pay to the Corporation deposit for the equipment as
per your terms currently in force.

I give below the consent from Shri/Smt. ___________________________ requesting Hindustan

Petroleum Corporation Ltd., to transfer his/her customership in my name and also authorizing
me to sign the Termination Voucher and accept refund of deposit amount on his/her behalf.

Thanking you,

Yours faithfully,

(ACTUAL HOLDER OF THE EQUIPMENT)

Shri/Smt. ________________________ hereby confirm that I have no objection to the

Corporation transferring the subject gas connection covered by Subscription Voucher no.
_____________ dated ___________ held by me to Shri/Smt. ____________________________
and I hereby explicitly authorize M/s Hindustan Petroleum Corporation Ltd., to do so and to
permit him/her to sign the TV as well as accept the refund of deposit on my behalf. I hereby
totally surrender my claim on this gas connection and shall not have any claim whatsoever at any
future date.

__________________________________
(SIGNATURE OF S. V. HOLDER)

(To be attested by a Magistrate/Notary Public under his Official Seal)