Appendix – XA

AFFIDAVIT

I, Nagaraj Naragund Son of Virupakshappa Naragund Age 30 years residing at At Pashupatihal,

Tq: Kundgol, Dist: Dharwad In connection with my application for RO dealership at Saunshi
Village, Dharwad (Dist.) Karnataka (State) I do hereby solemnly affirm and say as under :
1 That I am an Indian Citizen and resident of India (as per Income Tax Rules1)
2 That my date of 0 1 / 0 6 / 1 9 9 4
birth is
That I have passed the Matriculation / 10th Std. Examination conducted by 2 0 1 0
3 Board in the year / Certificate issued by Armed Forces as equivalent to 10th
Class pass in the year
That I hereby confirm that I am eligible for allotment of Retail Outlet dealership as per
applicability of Multiple Dealership Norm defined under Clause “Disqualification” in the
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“Brochure for Selection of Dealers for Regular & Rural Retail Outlets” and do not disqualify
for allotment of Retail Outlet dealership under other conditions mentioned therein.
That I hereby confirm that none of my family members (as defined under Clause
“DISQUALIFICATION” of brochure) are employees of Indian Oil Corporation Ltd., Bharat
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Petroleum Corporation Ltd. and Hindustan Petroleum Corporation Ltd.
6(a) That I am un married
or
that I am Married and the name of my spouse is Smt Revati
My name before my marriage was Shri/Smt/Kum__________and after my marriage to
6(b) Shri __________my name has been changed to Smt. _____________(only for female
applicants, wherever applicable)
That my name earlier was Shri/Smt/Kum______________and has been changed to
6(c) Shri/Smt/Kum __________ w.e.f. ___________ (Applicable in case of name change by
applicant)
7 That, I am of sound mental health & I am not totally paralyzed.
That I have never been convicted for any criminal offence involving moral turpitude and/or
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economic offences (other than freedom struggle).
I confirm that arrangement will be made for taking delivery of products on ex-MI basis from
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Oil Company within 4 months of intimation thereof from Oil Company to this effect.
 I hereby confirm that neither I nor any member of my “family unit” (as defined under
Multiple dealership norm for individuals/non-individuals of Disqualification criteria), was
10 ever 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
In case I am selected for RO dealership, I undertake to develop the desired infrastructure
and facilities at the Outlet allotted as per specification and timelines stipulated by Oil
11 Company IOCL in the advertisement/LOI and also undertake to arrange the working capital
for operation of the outlet as mentioned in the Advertisement for the location.

That the details mentioned in Clause No. 9 of the application form, affidavit of Co-owner/s
(if applicable) pertaining to Land: -

a) Are true and land documents in support of the claim would be submitted as and when
advised by Oil Company

b) That in case I am selected for RO dealership, I undertake to arrange the said plot as
mentioned in the application form for setting up of retail outlet at the location for which
I have made the application.

c) I am aware that my claim, as above, if not supported by required documents or in the

event being found to be at variance at any stage, would result in my application
/candidature becoming invalid for further consideration by Oil Company.

d) I am also aware that in the event of my inability to make available the said land required
for setting up the retail outlet as required by Oil Company, IOCL within the period
mentioned in the LOI, then the allotment can be withdrawn and I will have no
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claim/damages whatsoeveragainst Oil Company

e) I am also aware that in case of my selection for this RO dealership it will be binding on
me to hand over the offered land including the entry / exit / acceleration / de-
acceleration / service road duly developed up to the road level with good earth / murrum,
layer wise compacted as per standard engineering practices to the satisfaction of OIL
COMPANY and I will provide retaining wall and compound wall of minimum height 1.5
meter, designed as per site conditions and approved by OIL COMPANY engineers.

f) I am also aware that in the event of my inability to develop the requisite infrastructure
and facilities as per specification and timelines stipulated by OIL COMPANY IOCL in the
advertisement/LOI, the allotment can be withdrawn and I will have no claim/damages
whatsoever against OIL COMPANY. IOCL

g) I am also aware that in case the same piece of land offered by me for setting up of
retailoutlet at location At: Within Saunshi Village Village Lmits, Kundagol Taluka, SH73
in Dist Dharwad in State Karnataka is offered by any other applicant for the same
purpose, my candidature for RO dealership will be rejected.
 That I hereby confirm that I will neither take up any other employment nor will draw any
salary/perks/emoluments from State/Central Government upon my appointment as a
dealer.
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If I am already employed I will resign from the employment and produce proof of acceptance
of resignation by my employer before the acceptance of Letter of Appointment to be issued
by the oil Company.
I undertake that If selected, I shall be paying attention towards day to day working of the
14 dealership by personally managing the affairs of the dealership and will not be eligible for
taking up any employment
15 I am married. I undertake to fulfil the conditions of IOCL with regard to inducting Spouse as
Co-owner in the dealership if the dealership is awarded to me.
Or
I am unmarried I undertake to infrom the OIL Company of my marriage and undertake to
fulfill the conditions of _____________(Name of the oil Company) with regard to inducting
Spouse as Co-owner on the dealership within one year of my marriage if the dealership is
awarded to me.
I undertake that I will observe all the relevant guidelines, with regard to award/operation of
16 the said dealership, issued by Indian Oil Corporation Limited / Bharat Petroleum
Corporation Limited / IOCL / Government Of India or any other statutory body from time to
time.
That if any information/declaration given by me in my application or in any document
submitted by me in support of application for the award of the RO dealership or in this
17 affidavit shall be found to be untrue or incorrect or false, IOCL 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 OIL COMPANY for such withdrawal / termination.
That, if selected, I undertake that I will be depositing an interest free Security deposit of Rs.
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4 Lakhs as per the policy of Corporation.
That, if selected, I undertake that I will pay the non-refundable Fixed fee of Rs 15
19 Lakhs as per the policy of the Oil Company (Applicable for Dealer owned sites) (for DC Sites)
Or
That If I selected I undertake that I will pay the non refundable final Bid Amount (Applicable
for Corporation owned sites except for Corpus fund and ROs) (For CC Sites)
 I am aware that in the event of any proceedings pending against the
dealership/distributorship held by me or my “family unit” (as defined under Multiple
dealership norm for individuals/non-individuals of Disqualification criteria) on account of
critical/major irregularities for violation of Marketing Discipline Guidelines/Dealership
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Agreement, Control Orders or ESMA, Court cases, Show Cause notices, etc., the allotment
made will be conditional and subject to the outcome of such proceedings. I understand that
I will also not be entitled for any claim, damages, etc. in case of cancellation of allotment in
the event of adverse verdict in such pending proceedings.
I hereby confirm that my candidature has never been rejected/selection
cancelled/dealership or distributorship terminated by any of the OIL COMPANYs for
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providing false information/misrepresentation of facts/submitting false/fake documents
while applying for RO/SKO-LDO Dealership / LPG Distributorship
I also confirm that I am in possession of the supporting documents in original in respect of
the information given by me in the application for RO dealership at Within Saunshi
22 Village Village Lmits, Kundagol Taluka, SH73 in Dist Dharwad in State Karnataka of IOCL.
If selected, failure to present these documents in original will result in cancellation of
selection due to submission of false/unsupported information in this application.
Only for applicants applying under the category of SKO dealers* (*Strike off whatever is not
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applicable)
a. That I am the sole proprietor / partner of SKO dealership of the Name and style of at
(OMC Name) in (Location) operating below an average allocation of 75KL of SKO per
month during the immediate preceding 12 month prior to the month of advertisement
for the RO dealership.
b. That I have not been penalized for violation of marketing Discipline Guidelines within
last 5 years preceding the date of advertisement and / or there are no proceeding
pending against my dealership under Marketing Discipline Guidelines, Dealership
Agreement, Kerosene Control Order or ESMA.
c. That I am aware that if I am selected for the RO dealership, I will have to surrender my
SKO dealership before being appointed as RO dealer by IOC/BPC/HPC.

I hereby verify that what has been stated above is true and correct to the best of my
knowledge and nothingmaterial has been concealed there from.

Signature of Deponent
(Shri Nagaraj Virupakshappa Naragund)

Solemnly affirmed and declared before me. This 20th day of June 2024

Signature and Seal of Magistrate

Judge/Notary public
Note: The stamp paper should be purchased in the name of the deponent