Pradhan Mantri Ujjwala Yojna. Undertaking For Availing Loan On Refill/ LPG Stove (Tobe filled in black ink with BLOCK LETTERS. Al Fields are mandatory) [Consumer Det Name of Applicant Ms / Mrs 1 |First Name 2 |Middle Name 3 |Last Name [AHL Tin Number (AHL Tin number's indetified in the SECC list which belongs to an individual in the family) Loan Required for (Tick the appropriate box) Stove Refill Both |Dear LPG Distributor, 1 daughter/wife of. Age years, resident of desire to avail EMI loption for LPG stove / Fist refil/ Both in this connection for which seperate KYC form is attached and affirm as under :- a) here by declare that | have applied for Domestic LPG connection under Pradhan Mantri Ujjwala Yojna and cannot afford to buy the LPG stove and refil, hence a loan on EMI basis is requested by me on LPG stove / First refill / Both. bb) LPG stove / first refills purchased on loan from OMC, | authorize my OMC to recover the loan amount from the subsidy of the ‘refills availed by me. 1am fully aware that | will nt receive the subsidy amount of the refills purchase by me in my bank a/c till the time loan amount is fully recovered by the OMC. )_ there by Confirm that, The information furnished in this form is correct and nothing material has been concealed there from ‘and ! understand that, false information, if any will attracts punishment under Indian Penal Code. Date :- ‘Signature of person giving the Declaration Place :- Name =