Affidavit Statement Format by zqn11228

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									Format of affidavit to be furnished by prospective customers before availing of a new gas
connection in cases where the customer is not able to produce any other type of proof of
residence, being new in town.

(THIS AFFIDAVIT BOND IS TO BE TYPED ON RS. 20/- NON JUDICIAL STAMP PAPER
AND TO BE SIGNED BY DEPONENT IN THE PRESENCE OF A FIRST CLASS
MAGISTRATE                  /              NOTARY                 PUBLIC)
____________________________________________________________________
                                 Affidavit

I ____________________________ son/daughter/wife of________ aged______years make
the following declaration in respect of my present proof of residence.

    1. I am presently residing at ____________(full address with land mark)

    2. I do not have a Ration Card at the address indicated at Sl no.1 above.

    3. I have Ration Card bearing Number _______ of my old residence Located
       at old address ___________________for which I am drawing ration from shop
       named __________ located at__________(name & full address of the ration shop)

    4. I surrendered my old ration card bearing number____________, for which I am
       producing a copy of the surrender acknowledgement given the Dept. of Food &
       Civil Supplies.

    5. I do not have any other form of proof of address to be furnished to obtain my
       existing gas connection at Peenya.

    6. I am giving the above statement to Distributor in order to obtain my gas connection
       & above is true to the best of my knowledge & belief.

    7.   I am aware if the above statement is false, Karnataka Food & civil Department,
         Govt of Karnataka is free to take any legal action against me under Essential
         Commodities act of LPG Control Order 2000 or any other Rule or Act of the land.


DEPONENT


IDENTIFIED BY ME:
(Advocate)
Date:
                                                               SWORN TO BEFORE ME
                                                                           (Notary)

								
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