[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

Subscription number: 2424+1+245+8792

Consumption category: Household

[Emblem]

Iran National Gas Company

Code Form: F P 24-014/00

Gas line Number: 01-64-0100/90

Cash

Subscription Card

 

Name: Cemetery, Surname: Minority Religion – Baha’i, Subscription Date: 10/4/1392 [1 July 2013]

Building Foundation/Maximum Consumption Hourly Rate (m3) 136/650. Number of Units/No. of Gas Burners: 3

Metre Capacity: G 16, Cost of Installation of Extensions: 5,000,000, (Number of Instalments: --) rial

Bank Receipt Number: 907912 Date: 08/04/1392 [29 June 2013]

Subscription Services of: Kermanshah Region - Province of Kermanshah

[Signature over official stamp]

Gas Company - Province of Kermanshah

At the time of your appointment, bring [your] card.  No duplicate card will be issued if lost.