Supplementary KYC Document & Undertaking for Expanded PMUY
(To be submitted along with PMUY KYC Document) (PS: To be published in vernacular languages)
Name of the Applicant:
Aadhaar No of applicant
Select category in which applicant is applying for the gas connection under PMUY.
Code Category of Applicant applied in Category Document No. ( Photo copy to Date of issue Place of issue
be submitted) (dd/mm/yy)
01 SC/ST households
02 PMAY (Gramin)
03 Most Backward Class
04 Antyodaya Anna Yojana (AAY)
05 Tea and Ex Tea garden Tribe
06 Forest Dwellers
07 Islands & River Island
08 Poor HH as per 14 point
declaration
Undertaking for Availing LPG connection under Expanded Pradhan Mantri Ujjwala Yojana.
Dear LPG Distributor,
I,.............................................................daughter/wife of .............................Age................years, resident of
............................... ............................................... .......................................do hereby declare that I and my family do
not possess or meet any of the following exclusion criteria’s which will disqualify my application for LPG connection
under PMUY.
1) Motorized 2/3/4 wheeler / fishing boat.
2) Mechanized 3-4 wheeler Agricultural equipment.
3) Kisan credit card with credit limit of over Rs. 50,000/-.
4) Household member government employee.
5) Households with non-agricultural enterprises registered with government.
6) Any member of household earning more than Rs. 10,000 per month.
7) Paying income tax.
8) Paying professional tax.
9) 3 or more rooms with pucca walls and roof.
10) Owns a refrigerator.
11) Owns landline phone.
12) Owns more than 2.5 acres of irrigated land with 1 irrigation equipment.
13) 5 acres or more of irrigated land for two or more crop season.
14) Owning at least 7.5 acres of land or more with at least one irrigation equipment.
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I
undertake that if 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 , recover full loan amount if
availed , subsidy amount for refill transferred and that I would have no claim whatsoever against IOCL/BPCL/HPCL for
such withdrawal/Termination/Seizure/Forfeiture/recovery.
I hereby declare that the above is read out to me and explained by the distributor or his/her authorised person and I
have understood the same.
Name & Signature of the applicant giving declaration
Name.............................................. Sign................................................
Date............................................ Place..............................................
Certification by distributor
I confirm having received & verified the photocopies of documents submitted by the applicant
against their originals.
Signature & seal of distributor
Self - Declaration for continuation of application under PMUY
1. Name of the Distributor: 2. Mobile No:
(where cleared application
Is available)
3. Name: 4. Aadhaar Number:
5. Spouse’s Name: 6. Father’s Name:
7. Address:
District:
State:
I declare that the details submitted earlier in my application remain un-changed. OR
I declare that my family composition has changed since I submitted my earlier application. The family
members given below are also staying with me at the afore-mentioned address.
I declare that none of the family members in my household have any LPG connection at the address mentioned.
Name of the beneficiary/ DOB as per
Sl Aadhaar No. Relationship Gender
Name of family members Aadhaar
FAMILY MEMBERS TO BE ADDED
1
2
3
4
FAMLY MEMBERS TO BE REMOVED (only in case of death, marriage).
Supporting certificate to be uploaded as per existing SOP.
1
2
3
4
I declare that I am willing to continue my application under Pradhan Mantri Ujjwala Yojana.
Date of Declaration Signature/ LTI of the Applicant
DISTRIBUTOR TO FILL
1. Earlier Application Number:
2. Application Date:
3. Sub - Category of Application: PMUY/ EPMUY/ EPMUY 2
I declare that I have kept the earlier application and have checked that it meets the SOP of EPMUY3.
Verified by distributor (Signature)
