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PMUY LPG Connection Undertaking Form

The document is a Deprivation Declaration for Poor Households, which serves as a supplementary KYC document for applicants seeking an LPG connection under the Pradhan Mantri Ujwala Yojana. It includes a checklist of exclusion criteria related to income, assets, and existing LPG connections that must be met to qualify for the scheme. The applicant must declare the truthfulness of their information and acknowledges the consequences of providing false information.

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Karan
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32 views2 pages

PMUY LPG Connection Undertaking Form

The document is a Deprivation Declaration for Poor Households, which serves as a supplementary KYC document for applicants seeking an LPG connection under the Pradhan Mantri Ujwala Yojana. It includes a checklist of exclusion criteria related to income, assets, and existing LPG connections that must be met to qualify for the scheme. The applicant must declare the truthfulness of their information and acknowledges the consequences of providing false information.

Uploaded by

Karan
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Deprivation Declaration for Poor Households

(Supplementary KYC Document & Undertaking)

Name of the Applicant:


RAN 2
2
Aadhaar No. of Applicant: 5 | 3 3

Undertaking for availing LPG connection under Pradhan Mantri Ujwala Yojana

Dear LPG Distributor,


,RN (Name of applicant), daughter/wife of
(Name of Father/Husband), aged 43 years, resident of t 3 3 6 2 E
(Residential
my family
address of applicant), do hereby declare that and my family members (as per
which willdisquality
ComposItion) do not possess or meet any of the following exclusion criteria,
my application for LPG connection under PMUY.

Deprivation Checklist (Exclusion Criteria)


S. No. Exclusion Criteria Yes/No

Section A: Income/Employment Related


Anyof the members of household earning more than 10,000/- per
month. N
2 Paying professional Tax

Paying Income Tax


NO
4 Household member is a Government employee.

5
Household with non-agricultural enterprises registered with
government.

6 Possess Kisan credit card with credit limit of over 50,000/

Section B: Asset/ Wealth Related

Own more than 2.5 acres of irrigated land with 1 irrigation equipment.
seasone
Own 5 acres or moreof irrigated land tor two or more crop
with at least one irrigation
Own at least 7.5 acres of land or more
equipment.
NO

Page 1 of 2
HP
Bharat
Aeum &Natural Gas etrolo
Ament of India
IndianOil

Own ahouse of more than 30 sauare meter


10 carpet area (o NO
received through any government scheme).
11 Own motorized 3/4-wheeler/ fishing
boat.
12 Own mechanized 3/4-wheeler agricultural equipment. NO

Section C: Existing LPG Connection Related

13 Have Existing LPGConnection

Tnereby declare that the details furnished above are true and correct to the best of my knowledge
concerned Oil
and beliet. Tundertake that if anv of above is found untrue/incorrect/false, the
MarketingCompany (OMC) would be well within its rights to withdraw the supply of gas/terminate
my bank
my connection/seize the equipment/recover the subsidy amount transferred to
account/take legal action against fraudulent claims and that I would have no claim whatsoever
against IOCL/BPCL/HPCL for such withdrawal/termination/seizure/forfeiture/recovery/legal action.
Thereby declare that the above is read out to me and explained by the distributor/his/her
authorized person and Ihave understood the same.
Name & Signature of the Applicant

Name: Rani
Sign:

Date:

Place:

Certification by Distributor
lconfirm having received and verified the photocopies of documents submitted by the applicant
against their originals.

Signature & seal of distributor:

Page 2 of 2

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