I ABDUL SATTAR S/o ABDUL MAZEET MISHTRI Aged 49 Years an Indian
Inlibatant Resident of PANI KI TANKI KE BAJU ME, MAZEET MISHTRI SAGAR KRISHNGANJ Madhya Pradesh 470001 Do here by Solemnly Affirm and state as follows 1. That I am Consumer of HP Gas for domestic use at the above address Since 25/04/1998 my consumer number is 600962 I was issued with subscription voucher No. 1031636 dated 25/4/1998 by M/s Hindustan Petroleum Corporation Ltd. through HP Gas Distributors M/s Aditi Gas Agency 11053700 Towards a gas cylinder and regulator on loan for my use against the refundable deposit of Rs. 1,000.00 2. That I am not able to produce the subscription Voucher to obtain the Termination Voucher, as it is misplaced/ lost. 3. That I Shall be liable to M/s Hindustan petroleum corporation limited or the distributor for any loss or expenses incurred by them if any one else produce the above referred subscription voucher to claim any amount of other benefit from M/s Hindustan petroleum corporation Ltd. or their distributors. Solemnly Affirm by the within named At ...................... on this ................day of
) Deponent ) ) Signature VERIFICATION Verified that the constants of above paras 1 to 3 are true and correct to the best of my knowledge and belief. Deponent