AFFIDAVIT FOR CHANGE OF NAME
(HUSBAND TO WIFE)
From, Date: ______________________________
__________________________ (W/O __________________________ P)
Door No. __________________________ B2 Block, Phase – 1,
__________________________ Apartments, 4th main road,
__________________________ Chennai - __________________________
To,
__________________________ GAS AGENCIES
H-915, 6th Avenue, Anna Nagar West, Chennai – __________________________
GSTIN: 33__________________________ B1__________________________
__________________________ /Madam,
Sub: Regarding gas connection name transfer
I Mrs. __________________________ (W/O __________________________ P), aged ___ years, resident of India and occupied as homemaker hereby solemnly oath below:
1. That my husband (late Mr. __________________________ P) had a __________________________ Gas Connection from __________________________ GAS AGENCIES, __________________________ and Subscription Voucher (__________________________) No. __________________________ dated ______________________________
2. That my husband Mr. __________________________ P has expired on ______________________________.
3. That I request M/s __________________________ __________________________ to transfer the aforesaid connection in my name and allot me fresh consumer number.
4. That I indemnify M/s. __________________________ __________________________ and __________________________ GAS AGENCIES, __________________________ from any future claims raised by anybody in respect of the above requested change of name in __________________________ gas connection.
5. That in the event of any claims whatsoever, raised by anybody against the transfer of above referred connection in my name, I shall immediately surrender the equipment issued to me in respect to M/s __________________________ __________________________ unconditionally.
6. That I also confirm that I or any member of my family, as detailed in my ration card, do not possess any __________________________ connection from any Oil company.
…Continued on page 2
7. That the original Subscription Voucher of __________________________ P is lost/misplaced and it is not traceable. If it is found in future, I will handle it to M/s __________________________ __________________________ without using it anywhere for any purpose.
8. That the legal heirs of late __________________________ P have appended their signatures below expressing their No Objection for the above requested transfer of the __________________________ gas connection.
9. That there are no more legal heirs of late __________________________ P other than those appending their signatures below.
Solemnly affirmed by the within named at on the day of ______________________________.
__________________________ (__________________________ & __________________________ ) - We do not have any objection for transferring the __________________________ gas connection from late __________________________ P (Father) to __________________________ S (Mother) as requested above.
NAME
1. __________________________
(Relationship - Daughter)
2. __________________________
(Relationship - Daughter)
__________________________ that the contents of above paras 1 to 9 are true and correct to the best of my knowledge and belief. I am liable u/s 193,199,200 of __________________________ /__________________________ if any contents found false.
Deponent
(__________________________)
WITNESSES:
1.
Name, address and signature
2.
Name, address and signature
