ANNEXURE-D1

NotarizedAffidavit
(TO BET YPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)
Reconstitution of Retail Outlet Dealership at LOI Stage for the Location: ,
District: ,State: which was offered vide LOIno.
, dated

I, son/daughter/wife of
Age years residing at do
hereby solemnly affirm and say as under :
1 That I am an Indian Citizen and resident of India (as per IncomeTax Rules).
2 That my date of birth is d d / m m / y y y y (Age as on date of application for
reconstitution in
words )
*That I have passed the 10th Standard examination conducted by Board in the year y y y y
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4 * That I am unmarried. That neither I, nor my Father, Mother, unmarried brother(s), unmarried
sister(s) have dealership/distributorship or hold Letter of Intent for Retail Outlet or SKO-LDO
dealership or LPG distributorship of any Oil Company except the subject Retail Outlet Dealership for
Which Reconstitution is proposed#.
OR
* That I am married and name of my spouse is . That neither I nor my spouse,
unmarriedson(s)/unmarrieddaughter(s)havedealership/distributorshiporholdletterofIntent for Retail
Outlet or SKO-LDO dealership or LPG distributorship of any Oil Company except the subject Retail
Outlet Dealership for which Reconstitution is proposed #.

OR
* That I am widow / widower. That neither I nor my unmarried son(s) / unmarried daughter(s) have
dealership/ distributorship or hold letter of Intent for Retail Outlet or SKO-LDO dealership or LPG
distributorship of any Oil Company except the subject Retail Outlet Dealership for which
Reconstitution is proposed #.
OR
* That I am divorcee. That neither I , nor any of my unmarried son(s) / unmarrieddaughter(s) (whose
custody is given to me) have dealership/ distributorship or hold letter of Intent for Retail Outlet or
SKO-LDO dealership or LPG distributorship of any Oil Company except the subject Retail Outlet
Dealership for which Reconstitution is proposed #.
5 That I hereby confirmthat none of my family members (as per multiple dealership norms as defined in
Dealer Selection Guidelines of Oil Marketing Companies) are employees of Oil Marketing
Companies.
6 That I am of sound mental health & I am not totally paralyzed.
7 That I am married and my name before marriage was and after my marriage to Shri
Has been changed to Smt. .
8 That I have never been convicted by any Court of Law for any criminal offences involving moral
Turpitude and/or economic offences (other than freedom struggle).

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9 That I hereby confirm that I was never a signatory to dealership/distributorship agreement of any Oil
Company, which was terminated for proven malpractices and/ or for violations of provisions of the
Marketing Discipline Guidelines.
10 That I hereby confirm that I will not be taking up any other employment upon my appointment as a
dealer. If I am already employed I will resign from the employment and produce the letter of
acceptance of resignation by the employer before the acceptance of Letter of Appointment issued by
The Oil Company.
11 I hereby declare that I am neither employed in private sector nor drawing any
salary/perks/emoluments from State / Central Government.I also affirm that during the tenure of the
Dealership I will not draw any salary/perks/emoluments from State/Central Government/
Private Sector.
12 That presently I am not having any contract with any Oil Marketing Company as Service
Provider/Labour contractor/Job Contractor for any COCO RO
OR
That presently I am having a contract with an Oil Marketing Company as Service Provider/ Labour
contractor/Job Contractor for one COCORO (Name of COCO Location ,
Dist. , State , Oil Company name ). I also
know that if I am appointed as a Dealer, I will have to terminate this contract before issuance of Letter
Of Appointment.
13 That if any information/declaration given by me in my application or in any document submitted
bymeinsupport ofapplication for theawardoftheROdealership or inthisaffidavit shallbefound to be
untrue or incorrect or false, then Corporation would be within its rights to withdraw the letter of
intent/terminate the dealership (if already appointed) and that I would have no claim, whatsoever,
Against the Corporation for such withdrawal/ termination.

*Strike off whatever is not applicable. #Strike off the portion if not applicable.

I hereby verify that what has been stated above is true and correct to the best of my knowledge and
nothing material has been concealed there from.

Signature of Deponent
(PARUL SUYAL)

Solemnly affirmed and declared before me.This day of

Signature and Seal of