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Appendix – III A
Notarized Affidavit for offer of land from family member and/or third party supported by land
documents – All the joint owners of the land have to submit this affidavit individually.
In _____________________Son/Daughter/wife of ______ age _____ years resident of ________ do
hereby solemnly affirm and say as under: -
1. *I understand that as per definition, Family members for offer of land under “Owned” category
for Selection of Dealer for Regular and Rural Retail Outlets, comprise of (I) Self (ii) Spouse (iii)
Father/Mother including Step Father/Step Mother (iv) Brother/Sister/Step Brother/Step Sister (v)
Son/Daughter/Step Son/Step Daughter (vi) Son-in-law / Daughter-in-law (vii) Parents-in-law (viii)
Grand Parents (both maternal & paternal).
That I am a member of Family of (Shri/Smt./Kum.) ___________ (name), as per definition for
Selection of Dealer for Regular and Rural Retail Outlets, who has applied for Retail Outlet dealership
of IOC*/BPC/HPC* at ______ (location) under '____ ' category against the advertisement appeared
in newspaper dated _______.
(*Delete the above two paragraphs of Clause 1, if the land owner is not a family member)
That I, Shri/Smt/Kum _______________, own a piece of land singly / jointly bearing Gut/Survey No.
________ at _________ (village/ town), ________ Taluka, _____________ District in the State of
___________ admeasuring _____ mt (frontage) X _______ mt (Dept), having area ______ Sq.mts as
per the following details: OR That I, Shri/Smt ___________, singly / jointly hold a piece of land on
long term lease basis (___ years w.e.f _____) bearing Survey No. ____ at ______(Village/ Town),
_______ Taluk, _________ District in the State of _______ admeasuring _____ mt (frontage) X
_______ mt (Dept), having area ______ Sq.mts as per the following details:
Name(s) of the Name(s) of the Date of Khasra No/Gut
owner of Land / owner of Land / registration of No/Survey No Dimensions of land
Lease holder Lease holder sale deed/gift
deed / lease Frontag Min. Area
deed/ date of e in Depth of the
mutation metre in land
metre (Sq.m)
1.
2.
3.
*Strike off whichever is not applicable.
** Please qualify the relationship i.e. (I) Self (ii) Spouse(iii) Father/Mother including Step
Father//Step Mother (iv) Brother/Sister/Step Brother/Step Sister (v) Son/Daughter/Step Son/Step
Daughter (vi) Son- in-law / Daughter-in-law (vii) Parents-in-law (viii) Grand Parents (both maternal &
paternal)
2. That Shri/Smt/ Kum / M/s.(name of the Entity) __________ has applied for Retail Outlet
dealership of MRPL at _____ (location) under '___' category against the advertisement appeared in
_________ newspaper dated ______.
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3. That in case he/she/ M/s.(name of the Entity) is selected for RO dealership I will either
sell/transfer/lease the above mentioned piece of land to Oil Company or to Shri / Smt / Kum /
M/s.(name of the Entity) _______ for setting of Retail Outlet facilities at the above
mentioned location as per the site plan duly signed by me/all co-owners. In case of lease, I further
confirm that I have no objection if the subject piece of land leased to Shri / Smt / Kum / M/s. (name
of the Entity) ______________ is further leased/sub-leased to the MRPL by him/her as per terms of
the Oil Company.
That I have no objection if the above-mentioned land is used for setting up of Retail Outlet facilities
by Shri / Smt. / Kum / M/s. (name of the Entity) _____ at the above-mentioned location, as per the
site plan duly signed by me/all co-owners.
4. I hereby confirm that the said piece of land has not been offered by me to any other person for
Retail Outlet dealership of this location against the above-mentioned advertisement.
5. I hereby verify that what has been stated above is true and correct to the best of my knowledge,
and nothing has been concealed there from.
Solemnly affirmed and declared before me
This _____________________day of ____________________________________
Signature and Seal of
Notary Public
Name of Deponent and Relationship with applicant
