HIG Ver 1.

DECLARATION OF INCOME FOR AVAILING LPG SUBSIDY

Consumer Details
Consumer Name Mr / Mrs
Consumer No
LPG ID

Distributor Details
Distributor Name

M/s

Dear LPG Distributor,

I am aware that, as per the directive of Govt of India, dated 28/12/2015, LPG subsidy will not be available for LPG consumer, if the
consumer or his/her spouse had taxable income of more than Rs 10,00,000/- ( Rupees Ten Lacs) during the previous financial year
computed as per the Income Tax Act, 1961.
1. My or my spouse's annual income is more than Rs 10 Lacs

2. My or my spouse's annual income is less than Rs 10 Lacs

Please check the appropriate box

PAN Details
PAN No *(Consumer)

Don't have PAN

PAN No * (Consumer's Spouse)

Don't have PAN

* Pleae attach self attested copy of PAN Card

The information furnished above is correct and I understand that, false information, if any will attracts punishment under Indian
Penal Code.
In case of any revision in my / spouse's income level for subsidy eligibility, I will resubmit the declaration.

Date _____________________

Place_________________________

Signature of the Consumer

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ACKNOWLEDGEMENT SLIP
Received Declaration of Income from (Name)________________________________________________Con. No _____________

Date:

Sign & Stamp of LPG Distributor