I, ___________________________ S/o Sh. _________________________________, aged _______ years R/o ___________________________________________, Desire to take domestic LPG connection in my name and affirm as under:-

1.     I am an Indian citizen. 

2.     My date of birth is _____________________.

3.     That neither I, nor any other member of  the household (house hold 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.

4.     I do not have Ration Card in my name or 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 member of the ‘household’, the same shall be produced to the Oil Company LPG distributor for up-dating records.

5.     I am enclosing the following documents-

        (a) Copy of Passport (proof of residence)

        (b) Copy of Aadhaar card (proof of identity)

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 aide by all terms governing its use.

7.     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 Kanwal Gas Service 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 affidavit 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.

(Your Name)


Place: New Delhi

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