Aadhaar (UID)-POA01
Passport-POA02
Passbook/Bank Statement.-POA03
Ration Card/NFS Card-POA04
Driving Licence-POA05
Voter ID-POA06
Passbook/Post Ofce Account Statement-POA07
Water bill (issued in the last 3 months)-POA08
Electricity Bill (issued in the last 3 months)-POA09
Property Tax Receipt (issued in the last 1 year)-POA10
Insurance Policy-POA11
Signed Letter on letterhead comprising photograph issued a
bank-POA12
Photo ID comprising address/Signed Letter comprising photograph
issued by a recognised educational institution-POA13
Arms Licence-POA14
SSLC Book comprising photograph-POA15
NREGS Job Card-POA16
Freedom Fighter Card-POA17
Bhamashah Card/ Jan Aadhaar Card-POA18
Kissan Passbook-POA19
Registered Lease/Sale/Rental Agreement-POA20
Department of Posts issued Address Card comprising
photograph-POA21
State Government issued Caste and Domicile Certicate comprising
photograph-POA22
State/Union Territory Governments/Administrations issued
handicapped medical certicate or Disability ID Card-POA23
Government issued Marriage Certicate comprising address-POA24
Self-Declaration (for Migrants only)-POA25
a) Under Pradhan Mantri Ujjwala Yojna free
LPG connections are provided by Oil
Marketing Companies (OMCs) to the women
belonging to the Below Poverty Line (BPL)
households.
b) The scheme provides cash assistance to
cover the cost of Security Deposit of Cylinder,
Pressure regulator, cost of DGCC, Suraksha
hose and installation & administrative
charges. Further, Beneciary will also be
given Hot Plate & First LPG Rell.
c) On successful verication & conrmation
of non existance of PDS LPG connection
at your premises, LPG connection may be
released to you subject to applicable terms &
conditions.
*List of POA Documents
Details of Pradhan Mantri
Ujjwala Yojna
Paste your
Photo here
(IOC/ BPC/ HPC)
Pradhan Mantri Ujjwala Yojana
UJJWALA KYC Application
(To be lled in black ink with BLOCK LETTERS. All Fields are mandatory)
Consumer Details Migrant: Yes No
a) Name of Applicant Ms / Mrs (as per Aadhaar)
1 First Name
2 Middle Name
3 Last Name
4 Aadhaar
5 Mobile
Caste SC ST Others
b) Date of Birth
D D M M Y Y Y Y
b) Address for LPG connection / Contact Information
1 Proof of Address (POA) Category Code* P O A Mobile No.:
2 House/ Flat #, Name Floor No
3 Housing Complex/Building Land Mark
4 Street / Road Name
Area / Post
Ofce Name
5 City / Town
6 Village / Panchayat Pin Code
7 Block / Sub District E-mail ID
8 District
9 State
c)
Details of all Household members aged above 18 yrs as per ration card /any other state specic document authenticating Family members other than the Applicant
(consisting of people living together in a dwelling unit having common kitchen)/ Self Declaration (in case of Migrant only)
S
No
Relationship with Applicant Name
Gender
(M/F)
Aadhaar Number
(Attach copy of Aadhaar card)
Signature towards
consent of using
Aadhaar
1
2
3
4
5
6
d) Particulars of my Bank Account (attach copy of passbook/ bank statement/ cancelled cheque having name of account holder, A/C No. and IFSC code printed on it) #
1 Name in Bank Account
2 Bank Name
3 Branch Name 4. IFSC Code
5 Bank Account Number
e)
Ration Card/any other state specic document authenticating Family members details/ Self Declaration (in case of Migrants) (attach a copy of ration card/state specic document/
Annexure - I (in case of migrants)
1 State of Issue
2 Ration card Number/ State specic document Number
f) 14 Point declaration duly signed by benecery enclosed with KYC
Yes No
g) Migrant certication (Annexure - I)
Yes No
Equipment Selection (Tick the appropriacte box/ boxes)
1 Type of LPG cylinder desired (select the desired Equipmment) 5 kg. Cylinder 14.2 kg. Cylinder
2 Type of Burner desired 1 - Burner 2 - Burner
Version 5.0