Deprivation Declaration Form Ujjwala Yojana PDF

PDF Name	Deprivation Declaration Form Ujjwala Yojana
No. of Pages	2
PDF Size	0.21 MB
Tags	Application Form
PDF Category	Government
Source / Credits	pmuy.gov.in
Uploaded By	Pradeep

Deprivation Declaration Form Ujjwala Yojana - Summary

Deprivation Declaration Form under Pradhan Mantri Ujjwala Yojana (PMUY) is a mandatory self-declaration document required for eligible women applicants seeking a deposit-free LPG connection. Introduced by the Ministry of Petroleum and Natural Gas (MoPNG), this declaration certifies that the applicant’s household belongs to an economically disadvantaged or deprived background and does not already possess an active domestic LPG connection from any Oil Marketing Company (IOCL, BPCL, or HPCL).

Under Ujjwala 2.0, the government expanded the scheme to cover poor households who may not be listed in the Socio-Economic Caste Census (SECC) 2011 list through a 14-point exclusion declaration and deprivation criteria. Below is the complete information regarding the Ujjwala Deprivation Declaration Form, eligibility parameters, documents required, and step-by-step instructions on how to fill and submit it.

Also See – Ujjwala Yojana Form PDF

Ujjwala Deprivation Declaration Form – Highlights

Particulars	Details
Scheme Name	Pradhan Mantri Ujjwala Yojana (PMUY 2.0)
Administering Ministry	Ministry of Petroleum & Natural Gas (MoPNG), Govt. of India
Form Title	Deprivation / 14-Point Self-Declaration Form
Beneficiaries	Adult women (aged 18+) belonging to poor/deprived households
Covered LPG Companies	Indane (IOCL), Bharat Gas (BPCL), HP Gas (HPCL)
Key Benefits	Deposit-free 14.2 kg / 5 kg LPG connection, free stove (hotplate), safety hose, and 1st refill
Application Fee	Free of Cost (₹0)
Application Mode	Offline at local LPG Distributor & Online at pmuy.gov.in
Official Website	pmuy.gov.in
Toll-Free Helplines	1906 (LPG Emergency) \| 1800-266-6696 (Ujjwala Helpline)

Who Qualifies under the Deprivation Declaration?

To be eligible for a new Ujjwala 2.0 connection using the Deprivation Declaration, the applicant must be an adult woman (at least 18 years of age) belonging to any of the following categories:

Households listed in SECC 2011 deprivation categories (D1 to D7).
Scheduled Caste (SC) and Scheduled Tribe (ST) households.
Beneficiaries of Pradhan Mantri Awas Yojana (PMAY – Gramin & Urban).
Antyodaya Anna Yojana (AAY) ration card holders.
Forest dwellers and primitive tribal groups.
Most Backward Classes (MBC).
Tea and Ex-Tea Garden Tribes.
Residents of River Islands and Coastal Islands.
Poor migrant households (eligible under Annexure-I self-declaration without needing a native address proof).

14 Exclusion Criteria (Disqualifying Conditions)

In the declaration form, the applicant must affirm under oath that their household does NOT satisfy any of the 14 exclusion parameters:

1. Ownership of motorized two-wheeler, three-wheeler, four-wheeler, or fishing boat.
2. Ownership of mechanized agricultural equipment (tractor, harvester).
3. Kisan Credit Card (KCC) with credit limit of ₹50,000 or above.
4. Any household member serving as a regular government employee (Central/State/PSU).
5. Non-agricultural enterprises registered with the government.
6. Any family member earning more than ₹10,000 per month.
7. Paying Income Tax or Professional Tax.
8. House with three or more rooms with pucca walls and pucca roof.
9. Owning a refrigerator or landline telephone.
10. Owning 2.5 acres or more of irrigated land with at least one irrigation equipment.
11. Owning 5 acres or more of irrigated land for two or more crop seasons.
12. Owning at least 7.5 acres of land with at least one irrigation equipment.
13. Having an existing LPG connection in the same household from any OMC.
14. Furnishing false or misleading information to obtain government subsidies.

Documents Required for Ujjwala Application

The following self-attested documents must be submitted along with the completed Deprivation Declaration Form:

Applicant’s Aadhaar Card: Proof of Identity and proof of address for the female head of the family.
Aadhaar Cards of All Adult Family Members: For deduplication and verifying that no member has an existing connection.
Ration Card / Family Composition Document: State-issued Ration Card displaying family member details (or Annexure-I self-declaration for migrant families).
Bank Account Passbook: Bank account in the name of the applicant with IFSC code and Aadhaar linkage for DBTL subsidy credit.
Passport-Sized Photographs: 2 recent color passport photos of the applicant.
Category Proof (if applicable): SC/ST certificate, PMAY sanction letter, or BPL certificate.

How to Fill Ujjwala Deprivation Declaration Form

Follow the simple step-by-step instructions below to complete the declaration accurately:

Applicant Information: Write the applicant’s full name, husband’s or father’s name, residential address, state, district, PIN code, and active mobile number.
Family Members Table: Enter the names, relationship, gender, date of birth/age, and 12-digit Aadhaar number for each family member living together under the same roof.
Select Deprivation / Category Type: Check the appropriate box indicating your category (e.g., SC/ST, BPL, PMAY, or Poor Household under 14-point criteria).
No Prior LPG Connection Affirmation: Read the clause confirming that neither the applicant nor any member of the household holds an active domestic LPG cylinder connection from Indane, Bharat Gas, or HP Gas.
Sign the Declaration: Put the date and place, followed by the applicant’s signature or left thumb impression (LTI).
Submit to Gas Agency: Hand over the completed form with attached photocopies to your nearest LPG distributor (Indane, Bharat Gas, or HP Gas). The distributor will perform biometric e-KYC authentication and issue an acknowledgment slip.

Download Deprivation Declaration Form Ujjwala Yojana PDF: Applicants can download the official Hindi and English Ujjwala Yojana 14-Point Deprivation Declaration Form in printable PDF format using the link given below.