Pradhan Mantri Ujjwala Yojana

(To be filled in black ink with BLOCK LETTERS. All Fields are mandatory)

AHL Tin Number

Loan Required for (Tick one)

Stove Refill Both

Consumer Details

First Name

Middle Name

Last Name

Dear LPG Distributor,

I daughter/wife of , Age years, resident of desire to avail EMI option for LPG stove / First refill / Both in this connection for which a separate KYC form is attached and affirm as under:

I hereby declare that I have applied for a Domestic LPG connection under Pradhan Mantri Ujjwala Yojana and cannot afford to buy the LPG stove and refill, hence a loan on EMI basis is requested by me on LPG stove / First refill / Both.
LPG stove/first refill is purchased on loan from OMC, I authorize my OMC to recover the loan amount from the subsidy of the refills availed by me. I am fully aware that I will not receive the subsidy amount of the refills purchased by me in my bank a/c till the time the loan amount is fully recovered by the OMC.
I hereby Confirm that the information furnished in this form is correct and nothing material has been concealed therefrom and I understand that, false information, if any will attract punishment under the Indian Penal Code.

Place:

Date:

____________________________________

Signature of person giving the Declaration Name:

UJJWALA KYC Application

(Pradhan Mantri Ujjwala Yojana)

Paste your photo here

a) Name of Applicant

First Name

Middle Name

Last Name

b) Address for LPG connection / Contact Information

Proof of Address (POA) category Code*

Date of Birth (DDMMYY)

House/Flat #, Name

Street/Road Name

City/Town

District

State

Pin code

Mobile no.

Email Id

c) Details of Household members aged above 18 yrs

S.No	Relationship with Applicant	Name (First, Last)	Aadhaar Number	Gender (M/F)
1
2
3

PAHAL Joining Details

Name in Aadhaar Card

Aadhaar Number

Name in Bank Account

Bank Account Number

Bank Name & Branch

IFSC Code

Ration Card details

State of Issue

Ration card Number

Equipment Selection

1. Type of LPG cylinder desired:

14.2 kg cylinder5 kg cylinder

2. Do you need LPG stove from distributor?

YesNo

Declaration

I daughter/wife of , Age years, resident of desire to take a domestic LPG connection in my name and affirm as under:

I hereby confirm that the information furnished in this form is correct and nothing material has been concealed.
I shall not hold IOC/HPC/BPC/MoP&NG responsible for any delays/non-receipt of subsidy.
In case of any revision/change in the above information, I will inform the LPG distributor.
I authorize my Oil Company/my bank to update/share my Aadhaar No./demographic data/bank account details for de-duplication/authentication/verification purposes.
In the event of any violation of Government Regulation, the Oil Company has the right to discontinue supply of LPG cylinders to me and forfeit the security deposit.
I am an Indian citizen and eligible for subsidized LPG.
My date of birth is (a person under 18 years of age is not eligible).
Neither I, nor any other member of my household, possess any other LPG connection or Piped Natural Gas Connection.
I confirm that the LPG connection will be used at my above-mentioned address for domestic cooking purpose only.
I shall not position any other LPG gas installations in the same kitchen.
Whenever I change my residence, I will inform M/s. (name of Distributor) in writing.
I am aware that this connection is subject to de-duplication checks.
If any information is found to be untrue, the Oil Company has the right to withdraw the supply of Gas, terminate the connection, and seize the equipment.

Place:

Date:

_______________________

Signature of Applicant Name:

ACKNOWLEDGEMENT SLIP

Received Ujjwala Application from (Name) , AHL Tin Number .

Date:

Signature & Seal of Distributor