Epmuy-2 Kyc Form
Epmuy-2 Kyc Form
Epmuy-2 Kyc Form
2 Middle Name
3 Last Name
PMUY / EPMUY /EPMUY- 2 Sub Category : SC / ST / OBC / Others (drop down to be provided)
8 District
9 State
c) Details of all Household members aged above 18 yrs as per ration card ( consisting of people living together in a dwelling unit having common kitchen)
Gender(M/F)
Relationship with Aadhaar Number ( Attach copy of
Sno Applicant Name ( First Name , Last name) Aadhaar card)
2 Aadhaar Number
d) PARTICULARS OF MY BANK ACCOUNT (attach copy of passbook/ bank statement/ cancelled cheque having name of account holder,A/C No. and IFSC code printed on it ) #
1 Name in Bank Account
2 Bank Name
3 Branch Name
4 IFSC Code
e) Ration Card details ( attach a copy of ration card) Mandatory for all new categories #
1 State of Issue
Page 1
f) 14 point declaration duly signed by beneficery enclosed with KYC Yes No
Equipment Selection ( Tick the appropriacte box/ boxes)
1 Type of LPG cylinder desired ( select the desired Equipmment) 14.2 kg cylinder 5 kg cylinder
Page 2
Dear LPG Distributor,
I _____________________________________son/daughter/wife of ____________ Age _________years, resident of________________________________________________
b) I shall not hold IOC/HPC/BPC/MoP&NG responsible for any delays/non receipt of subsidy in case of change/closure/deactivation of my Bank Account/ Bank not in NACH or for
any rejection by Bank or non-confidentiality of any information.
c) In case of any revision/change in the above information ,I will inform the LPG distributor.
d) I authorize my Oil Company/my bank to update/share my and my family member Aadhaar No./demographic data/bank account details between themselves and with outside
agencies for de-duplication/ authentication/ verification purposes.
e) In the event of any violation of Government Regulation related to the supply and distribution of LPG, IOC/BPC/HPC will be within its right to discontinue supply of LPG cylinders to
me, forfeit of security deposit and levy of penal charges as per the policy and guidelines and may initiate legal action applicable under provisions
f) That I am an Indian citizen/Non Resident Indian/Staff of Foreign nationality serving in India/Foreign national residing in India under valid visa/person returning to India on
transfer of residence basis/PIO *Tick whichever is applicable. Only Indian citizens are eligible for subsidized LPG.
g) That my date of birth is _________________ (LPG connection cannot be provided to a person under 18 years of age)
h) That neither I, nor any other member of the household (household means a family consisting of all members reflecting in the ration card living together in a dwelling unit having
common kitchen),posses any LPG connection from PSU Oil Companies or Piped Natural Gas Connection for domestic use in our dwelling unit. (‘Households’ having Piped Natural
Gas connection are not entitled for subsidized LPG).
i) 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 abide by all terms governing its use.
j) That I shall not position any other LPG gas installations in the same kitchen.
k) 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.
l) That whenever I change my residence from present address to another, I will inform M/s. ______________________________________ (name of Distributor/RGGLV) in writing
in advance for change of address in the records.
m) 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 declaration and information submitted by me in this 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’ .
n) 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.
o) I and my family members are willingly and knowingly sharing the Aadhaar numbers and aadhaar documents with OMC’s to avail the LPG connection
To be filled by Dealer/Distributor based on the category in which applicant is applying and submitting its documents.
f)
01 SC/ST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
02 PMAY
06 Forest Dwellers
07 River Island
08 SECC HH (AHL-TIN)^ NA
^( AHL Tin number is indetified in the SECC list which belongs to an individual in the family)
Page 3
# I confirm having verified the photocopies of documents above against their originals.
ACKNOWLEDGEMENT SLIP
Received Ujjwala Application from (Name)__________________________________________________________Place _____________________________
Document No.
( AHL Tin number is indetified in the SECC list which belongs to an individual in the family)
Page 4