MDBTL Version 2.0/ai-14 Sr. No. Form 4 Mandate for Non-Aadhaar based LPG Subsidy Transfer (To be submitted to LPG distributor) 1, Distributor (Name), District State. Oil Co. (TOCL/BPCL/HPCL) ‘Sub: Authorization to update my Bank Account details for receiving LPG Subsidy through NEFT/NACH T hereby affirm that I have only one subsidized LPG connection. 1 also affirm that I do not possess an Aadhaar Number and confirm my choice to opt for payment of amounts due to me towards LPG Permanent Advance and Refill Subsidy through NEFT/NACH to my bank account, 1 authorize my OMC to seek confirmation of my bank/Aadhaar details from my bank and also authorize my bank to release details of my bank account (number, name, address, Aadhaar number, mobile number etc.) to my OMC for purposes of this scheme, My LPG connection and bank account details are as under: PART A: LPG CONNECTION DETAILS (attach copy of Cash Memo or DGCC book or cert from Distributor/OMC) LPG Consumer No T7 agit PG ID (Dorr fil anything in 2) ‘Name exactly as it appears in LPG Connection (GN BLOCK LETTERS) Mobile No? +fo fa "Please provide mobile no. In case you do not have @ mobile no. you can give the mobile no. of any of your family member Please note that the mobile no. provided by you will be updated in the LPG database and will overwrite the earlier mobile no. if any, PART B: PARTICULARS OF MY BANK ACCOUNT (attach copy of passbook or cancelled cheque) ‘appears in his/her Bank Aecount (IN BLOCK LETTERS) Consumers Bank AccoUAE Number Fist NaS Consumers Mile Namie Consumers Last Wane Name of Consumer's Bank Name of Bank Branch IFSC Code (11 aigit*) or MICR Code (9 digit=*) as applicable available in your cheque book or with your Branch Manager. **MICR Code is applicable only where IFSC code is not available. Please check with your bank, if in doubt. NOTE : All fields in Part A & B above are mandatory Thereby confirm that + The facts stated above are true and correct to best of my knowledge and belief. + Twill advise any changes to the Distributor/Company. + T shall not hold IOCL/HPCL/BPCL/MoPENG responsible for any delays/non receipt of subsidy In case of change/closure/deactivation fof my Bank Account or for any rejections by the Bank or non- confidentiality of the above information. + I further confirm that 1 do not have Aadhaar number as on date. As soon as I receive the Aadhaar number, I will ink the same t my LPG Consumer Number by giving a copy of the same to my distributor and also get it linked to my above Bank account. + Ihave attached a copy of passbook/cancelled cheque with bank account details to this application + Talso understand that any false declaration attracts punishment under Indian Penal Code. Date: Signature of the Consumer ACKNOWLEDGEMENT SLIP Received Non Aadhaar Cash Transfer mandate ‘Form 4" from (Name), Con. No along with copy of passbook/cancelled cheque. Dat: Sign & Stamp of LPG Distributor