MOBIL Version 1.0/11-14
Sr. No.
Form 3
Mandate for Non-Aadhaar based LPG Subsidy Transfer
(To be submitted to Bank)
To,
The Branch Manager,
Name of Bank
Name of Branch
Sub: Authorization to update my LPG ID in the Bank Account for receiving LPG Subsidy through NEFT/NACH
Thereby affirm that I have only one subsidized LPG connection, I also affirm that I do not possess an Aadhaar Number and
confirm my choice to apt for payment of amounts due to me towards LPG Permanent Advance and Refill Subsidy through
NEFT/NACH to my bank account, My 17 digit LPG ID for the purpose of seeding it against my Bank account is given below:
PART A: LPG CONNECTION DETAILS (attach copy of Cash Memo or DGCC book or certificate
from Distributor/OMC)
LPG Consumer No.
17 agh PG ID
(Dorr fil anything in 2)
‘Name exactly as it appears
in LPG Connection
(GN BLOCK LETTERS)
Name of LPG
Distributorship
Consumer of
BPCL/HPCL/TOCL
available on your refill cash remo and on website www.MyLPG.in
PART B: PARTICULARS OF MY BANK ACCOUNT
Name exactly 6s isin
the Bank Account
(IN BLOCK LETTERS) First Name: idle Name Last Name
Bank Name
Branch Name
IFSC Code*
Bank Account Number
Mobile Number ylola
*hvallable in your cheque book or with your Branch Manager
NOTE : Alll 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 changes if any tothe Bank
+ Tunderstand that my bank account detells (neme, account, address/Aadhaar number) will be shared with BPCL/HPCL/TOCL for
the purpose of transfer of LPG Subsidy into my above Bank account
+ Tfurther confirm that Ido not have Aadhaar number as on date. As soon as I receive the Rachaer number, I wl ink the same to
ry above Bank account and LPG Consumer Number.
+ Thave attached a copy of Cash Memo/ blue boak/certificate from Disteibutor/OMC as a proof of my being an LPG consumer with
this application
+ Talso understand that any false declaration attracts punishment under Indian Penal Code.
Place
Date: ____ Signature of the Consumer
3S
ACKNOWLEDGEMENT SLIP
Received Non Aadhaar Cash Transfer mandate ‘Form 3" from (Name), .
‘Account Number along with copy of Cash Memo/DGCC book/certificate from Distributor/OMC.
Dati Sign & Stamp of Bank