MDBTL Version 2.0/11-14 Sr. No. Z Form 5 Mandate for Opting Out of Subsidy and PAHAL (DBTL) Scheme (To be submitted to LPG distributor) To, Distributor (Name) District State Name of Oil Company: 10cLC] / 8PCLL]/ HPcL [] (Tick one) Sub: Mandate for Opting Out of Subsidy and PAHAL (DBTL) Scheme Thereby at ‘m that I do not want LPG subsidy and thus I am voluntarily opting out of the DBTL scheme. My LPG connection details are as under: LPG CONNECTION DETAILS [attach copy of Cash Memo/copy of DGCC Book and Proof of Identity (POI)] LPG Consumer No 17 digit PG 1D (Bont rit anything in x) Name exactly as it appears) Consumers Ret Name Cansner = MSIE Nae Coraarer aS Tae in LPG Connection (IN BLOCK LETTERS) POI Category Code* pfo|t Mobile No# +fofa 4#PI provide mobile no. in case you do not have a mobile no. you can give the mobile no. of any of your family member. Pl. note that the mobile no. provided by you will be updated in the LPG database and will overwrite the earlier mobile no, if any. *As per POI Table (given below) Thereby confirm that: + Henceforth, I want to be supplied all my domestic LPG cylinders against the LPG connection at market price + The facts stated above are true and correct to best of my knowledge and belief. + T shall not hold IOCL/HPCL/BPCL/MoP&NG responsible for my opting out of PAHAL (DBTL) scheme. ‘+ In case I change my stand, I will advise the Distributor/Company and abide by the then prevailing guidelines in this regard Place: Date: Signature of the Consumer = (Only the LPG consumer him/herself has to sign above) POI Table [At least copy of one of the dacuments listed below should be attached and category mentioned in the form. Consumer is required to produce the original of the document for verification by the distributor. List of documents Category Code List of documents Category Code ‘adhear Number (UID) Port Voter 1D Card POIs Passport Number PoI02 Cte POTS PAN Card Number P0103 Driving License POTS ‘ACKNOWLEDGEMENT SLIP Received Mandate for Opting Out of Subsidy and PAHAL (DBTL) Scheme Form 5 (Name), on. No Dat Sign & Stamp of LPG Distributor