Appendix - 4
Notarized Affidavit for offer of land from member of the family unit/parents/grandparents (both paternal
& maternal) of the applicant and third party - All the joint owners of the land (except the applicant) have
to submit this affidavit individually including the member of the family unit /parents/grandparents (both
paternal & maternal) of the applicant.
(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)
I, ________________________ Son/Daughter/wife of _______________________________, age ________
years resident of _________________ do hereby solemnly affirm and say as under :
1. That I, Shri/Smt ________________________, own a piece of land jointly or Jointly Leased, bearing
Gatta/Khasra/Survey No. ____________ at _______________ (village/town), Taluka/Tehsil
_________________, Dist __________________ in the State of ___________________ as per the
following details:
* Land for Godown:
Names of the Joint Date of Khasra No./ Total Dimension of Dimension of
Owner(s)/ Joint Lessee registration of Gatta No./ the plot of Land Land offered as
Sale Deed/ Gift Survey No. (____ metres per Demarcated
Deed/ Lease X_______ metres) Plan (____ metres
Deed/ Date of X_______ metres)
Mutation
*Land for Showroom:
Names of the Joint Date of Khasra No./ Total Dimension of Dimension of
Owner(s)/ Joint Lessee registration of Gatta No./ the plot of Land Land offered as
Sale Deed/ Gift Survey No. (____ metres per Demarcated
Deed/ Lease X_______ metres) Plan (____ metres
Deed/ Date of X_______ metres)
Mutation
* Strike out whichever is not applicable
2. That Shri/Smt _____________________________ has applied for LPG Distributorship of
IOC*/BPC*/HPC* at _______________________ (location) under '________________' Category
against the advertisement appeared in _________________ news paper dated _________________.
That in case he/she is selected for LPG Distributorship, I confirm that I do not have any objection for
the construction of the LPG godown and/or showroom (as required by OMC) at the above mentioned
location, as per the demarcation on the site plan enclosed, duly signed by all co-owners.
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3. I hereby verify that what has been stated above is true and correct to the best of my knowledge, and
nothing has been concealed therefrom.
I also confirm that I have not offered this piece of land to any other person for the above purpose.
Name(s) Signature
Solemnly affirmed and declared before me
This ____________________ day of ________________
Signature and Seal of Signature of person making affidavit
Magistrate/Judge/Notary public (Name in block letters)
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