FORM NO. 'W'

I___________________________________of __________________
do hereby on solemn affirmation declare as under -

              That the Consumer Shri ___________________________
________________________________is my __________________
He/She died on _________________________________________I
have produced the death Certificate alongwith my application form. I declare that I am the only heir of the said deceased and have inherited all the movable and immovable properties togetherwith liabilities, past and future. I am willing to take-over all the past and future liabilities in respect of Electrical Energy and hire at Electric installation No. _______________

             I am agreeable to execute a fresh agreement in order to take all the benifits together with liabilities, past and future in respect of the supply of electrical energy and hire of electric installation No. ____________________ from the Maharashtra State Electricity Board and pay for the same and abide by terms and conditions of the said Board on the terms and conditions herein mentioned and further undertake to hold M.S.E. Board or its agents harmless and indemnified against all claims of any other persons claiming any rights to the said service, howsoever, by reason of your agreeing to the transfer the same to my name and hereby also agree to pay up all the arrears and to discharge all the liabilites of the outgoing consumer.

Solemnly declared

At ____________ on his ___________ day of __________19

We consent to the transfer                         Signed on behalf of
applied for

1.
2.
3.

heirs of the deceased                                   (i.e. Transferer)

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