Pradhan Mantri Ujjwala Yojana UJJWALA KYC Application

Aadhaar (UID)-POA01

Passport-POA02

Passbook/Bank Statement.-POA03

Ration Card/NFS Card-POA04

Driving Licence-POA05

Voter ID-POA06

Passbook/Post Ofce Account Statement-POA07

Water bill (issued in the last 3 months)-POA08

Electricity Bill (issued in the last 3 months)-POA09

Property Tax Receipt (issued in the last 1 year)-POA10

Insurance Policy-POA11

Signed Letter on letterhead comprising photograph issued a

bank-POA12

Photo ID comprising address/Signed Letter comprising photograph

issued by a recognised educational institution-POA13

Arms Licence-POA14

SSLC Book comprising photograph-POA15

NREGS Job Card-POA16

Freedom Fighter Card-POA17

Bhamashah Card/ Jan Aadhaar Card-POA18

Kissan Passbook-POA19

Registered Lease/Sale/Rental Agreement-POA20

Department of Posts issued Address Card comprising

photograph-POA21

State Government issued Caste and Domicile Certicate comprising

photograph-POA22

State/Union Territory Governments/Administrations issued

handicapped medical certicate or Disability ID Card-POA23

Government issued Marriage Certicate comprising address-POA24

Self-Declaration (for Migrants only)-POA25

a) Under Pradhan Mantri Ujjwala Yojna free

LPG connections are provided by Oil

Marketing Companies (OMCs) to the women

belonging to the Below Poverty Line (BPL)

households.

b) The scheme provides cash assistance to

cover the cost of Security Deposit of Cylinder,

Pressure regulator, cost of DGCC, Suraksha

hose and installation & administrative

charges. Further, Beneciary will also be

given Hot Plate & First LPG Rell.

c) On successful verication & conrmation

of non existance of PDS LPG connection

at your premises, LPG connection may be

released to you subject to applicable terms &

conditions.

*List of POA Documents

Details of Pradhan Mantri

Ujjwala Yojna

Paste your

Photo here

(IOC/ BPC/ HPC)

Pradhan Mantri Ujjwala Yojana

UJJWALA KYC Application

(To be lled in black ink with BLOCK LETTERS. All Fields are mandatory)

Consumer Details Migrant: Yes No

a) Name of Applicant Ms / Mrs (as per Aadhaar)

1 First Name

2 Middle Name

3 Last Name

4 Aadhaar

5 Mobile

Caste SC ST Others

b) Date of Birth

D D M M Y Y Y Y

b) Address for LPG connection / Contact Information

1 Proof of Address (POA) Category Code* P O A Mobile No.:

2 House/ Flat #, Name Floor No

3 Housing Complex/Building Land Mark

4 Street / Road Name

Area / Post

Ofce Name

5 City / Town

6 Village / Panchayat Pin Code

7 Block / Sub District E-mail ID

8 District

9 State

Details of all Household members aged above 18 yrs as per ration card /any other state specic document authenticating Family members other than the Applicant

(consisting of people living together in a dwelling unit having common kitchen)/ Self Declaration (in case of Migrant only)

Relationship with Applicant Name

Gender

(M/F)

Aadhaar Number

(Attach copy of Aadhaar card)

Signature towards

consent of using

Aadhaar

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

5 Bank Account Number

Ration Card/any other state specic document authenticating Family members details/ Self Declaration (in case of Migrants) (attach a copy of ration card/state specic document/

Annexure - I (in case of migrants)

1 State of Issue

2 Ration card Number/ State specic document Number

f) 14 Point declaration duly signed by benecery enclosed with KYC

Yes No

g) Migrant certication (Annexure - I)

Yes No

Equipment Selection (Tick the appropriacte box/ boxes)

1 Type of LPG cylinder desired (select the desired Equipmment) 5 kg. Cylinder 14.2 kg. Cylinder

2 Type of Burner desired 1 - Burner 2 - Burner

Version 5.0

Dear LPG Distributor,

I, son/daughter/wife of Age years, resident of

desire to take domestic LPG connection in my name and afrm as under:

a) I here by conrm that, the information furnished in this form is correct and nothing material has been concealed and I understand that, false information,

if any will attract punishment under Indian Penal Code.

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-condentiality 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/ verication 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, withdrawal of Equipment including Hot Plate 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 and residing in India.

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 reecting in the family composition 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 conrm 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 or my mobile no., I will inform M/s.

(name of Distributor/RGGLV) in writing in advance for change of address/ Mobile no. 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

is 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 including Hot plate/forfeit the security deposit, Recover cost of rst rell & subsidy received and that I would have no claim whatsoever

against IOCL/BPCL/HPCL for such withdrawal/Termination/Seizure/Forfeiture/Recovery.

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.

ACKNOWLEDGEMENT SLIP

Received Ujjwala Application from (Name) Place

Document No.

Ration Card Number/any other state specic document number which is authenticating Family members details

Signature & Seal of Distributor

Date:

To be lled by Dealer/Distributor based on the category in which applicant is applying and submitting its documents.

f) Select category in which applicant is applying for the gas connection under PMUY #

Code

Category of Applicant

applied in

( Put Check in the box)

Document No.

Doc.Date of

issue

(DD/MM/YY)

Place of

Issue

01 SC

02 ST

03 PMAY

04 Most Backward Class

05 Antodaya Anna Yojana (AAY)

06 Tea Tribe and Ex Tea Tribe

07 Forest Dwellers

08 River Island

09 SECC HH (AHL-TIN)^

10 Poor HH as per 14 Point declration NA

^(AHL Tin number is indetied in the SECC list which belongs to an individual in the family)

# I conrm having veried the photocopies of documents above against their originals.

LPG ID (If allotted):

Signature of Distributor



Signature/Thumb impression of Applicant

Name:

Date:

Place: