ACKNOWLEDGEMENT NUMBER: N- 881060182181130

Form No. 49A

Only ‘Individuals’ Application for Allotment of Permanent Account Number Only ‘Individuals’
to affix recent [In the case of Indian Citizens/lndian Companies/Entities incorporated in India/ to affix recent
photograph photograph
(3.5 cm x Unincorporated entities formed in India] (3.5 cm x
2.5 cm) Under section 139A of the Income Tax act, 1961 2.5 cm)
To avoid mistake (s), please follow the accompanying instructions and examples before filling up the form

Assessing officer (AO code)

Sign/ Left Tumb impression AREA CODE AO TYPE Range Code AO NO
across this photo
LKN C 53 1

Sir, I/We hereby request that a permanent account number be allotted to me/us.
I/We give below necessary Signature/Left Thumb Impression

1. Full Name (Full expanded name to be mentioned as appearing in proof of identity/address documents: initials are not permitted)
Please select title, as applicable Shri Smt. Kumari M/S
Last Name/Surname GUPTA
First Name ADITYA
Middle Name

2. Abbreviations of the above name, as you would like it, to be printed on the PAN card
ADITYA GUPTA
3. Have you ever been known by other name?
If yes, please give that other name Yes No
Please select title, as applicable Shri Smt. Kumari M/S
Last Name/Surname
First Name
Middle Name

4. Gender(for individual applicants only) Male Female

5. Date of Birth/Incorporation/Agreement/Partnership or Trust Deed/ Formation of Body of individuals or association of Persons

Day Month Year
16-01-1995

6 . Details of Parents (applicable only for individual applicants)

Last Name/Surname GUPTA
First Name KUMAR
Middle Name PRADEEP

Mother’s Name (optional)

Last Name/Surname
First Name
Middle Name

Parent name which is to be printed on the card Father's name Mother's name
7. Address
Residence Address
Flat / Room / Door / Block No. 294/12 BAZAAR KHALA
Name of Premises / Building / Village NAUBASTA ROAD
Road / Street / Lane/Post Office CHOWK
Area / Locality / Taluka/ Sub- UTTAR PRADESH
Town / City / District LUCKNOW - 226003

State / Union Territory Pincode / Zip code Country Name

Uttar Pradesh 226003

Office Address
Name of office
Flat / Room / Door / Block No.
Name of Premises / Building / Village
Road / Street / Lane/Post Office
Area / Locality / Taluka/ Sub- Division
 Town / City / District

State / Union Territory Pincode / Zip code Country Name

8. Address for Communication Residence Office

9. Telephone Number & Email ID details
Country code Area/STD Code Telephone / Mobile number

91 7619992526
Email ID ADIGUPTA510.AG@GMAIL.COM

10. Status of applicant

Government
Individual Hindu undivided family Company Partnership Firm Association of Persons

Trusts Body of Individuals Local Authority Artificial Juridical Persons Limited Liability Partnership

11. Registration Number (for company, firms, LLPs etc.)

12. In case of a person, who is required to quote Aadhaar number/ the Enrolment ID of Aadhaar application form as per section 139AA.
Please mention your AADHAAR number (if allotted) 3021 4569 7979
If AADHAAR number is not allotted, please mention the enrolment ID of Aadhaar application

Name as per AADHAAR letter/card or as per the Enrolment ID of Aadhaar application

Aditya Gupta
13. Source of Income
Salary Capital Gains
Income from Business / Business/Profession [For Code: Refer instructions] Income from Other sources
Income from House property No income
14. Representative Assessee (RA)
Full name, address of the Representative Assessee, who is assessible under the Income Tax Act in respect of the person, whose
particulars have been given in the column 1-13.

Full Name (Full expanded name : initials are not permitted)

Please select title as applicable Shri Smt Kumari M/s

Last Name/Surname
First Name
Middle Name

Address
Flat / Room / Door / Block No.
Name of Premises / Building /
Road / Street / Lane/Post Office
Area / Locality / Taluka/ Sub- Division
Town / City / District

State / Union Territory Pincode

15. Documents submitted as Proof of Identity (POI), Proof of Address (POA) and Proof of Date of Birth (DOB)
I/We have Copy of AADHAAR Card issued by the Unique as proof of identity Copy of AADHAAR Card issued by the Unique

as proof of address and Copy of Aadhaar Card issued by the Unique Identification as proof of date of birth.
[Please refer to the instructions (as specified in Rule 114 of I.T. Rules, 1962) for list of mandatory certified documents to be submitted as

[Annexure A, Annexure B & Annexure C are to be used wherever applicable]

16 I/We SELF the applicant, in the capacity of Himself/herself

do hereby declare that what is stated above is true to the best of my/our information and belief.

Place LUCKNOW
DD MM YYYY
Date 31-10-2017
Signature / Left Thumb Impression of
Applicant (inside the box)
 ACKNOWLEDGEMENT NUMBER: N- 881060182181130

Citizen of India Y
Category Individual
Name Shri ADITYA GUPTA
Name to be
ADITYA GUPTA
printed on card
Father's Name Shri KUMAR PRADEEP GUPTA

Date of Birth 16-01-1995

Residential 294/12 BAZAAR KHALA
Address NAUBASTA ROAD
CHOWK
UTTAR PRADESH
LUCKNOW - 226003
Uttar Pradesh
Office Address
Address for
RESIDENTIAL
Communication
Telephone No. 91 7619992526
Email ID ADIGUPTA510.AG@GMAIL.COM
Aadhaar No. 3021 4569 7979
Name as per Aadhar
No. Aditya Gupta

Payment Mode

e-Wallet: Your Payment of ` 110 (inclusive of Goods & Services Tax) through CSC Portal against transaction number 400-6992244 has been successfully processed.

Date: 31-10-2017

Instructions:
1. The acknowledgement number above is your unique reference number for PAN application. Kindly quote this number for tracking
the status of your PAN application on https://tin-nsdl.com or any queries relating thereto.
2 Save and print this acknowledgement.
3 Individual applicants affix your recent colour photograph (3.5 cm x 2.5 cm), sign the acknowledgement (inside the box provided
without touching the sides and in BLACK INK only) and enclose a Demand Draft (DD), if any, alongwith Proof of Identity, Proof
of Address and Proof of Date of Birth as specified in the application form.
4 Superscribe the envelope with 'APPLICATION FOR PAN -N - Acknowledgement Number' (e.g. 'APPLICATION FOR
PAN -N - 881010100000973').

5 Send the documents as specified in point no. 4 above to INCOME TAX PAN SERVICES UNIT (Managed By NSDL e-
Governance Infrastructure Limited) 13/D Kurla Industrial Estate, Nari Seva Sadan Road, Narayan Nagar, Ghatkopar
(West), Mumbai – 400 086 Tel: 020-27218080; Fax: 020-27218081.
6 Your acknowledgement, Demand Draft if any, and proofs, should reach NSDL within 15 days from the date of online application.
7 Application will be processed only on receipt of relevant proofs and realisation of payment.

8 PAN card will be dispatched only to the communication address provided in your PAN application. Wherever the
Representative Assessee (RA) details ( item no.14 in Form 49A ) are mentioned in the application, PAN card will be dispatched to
the RA's address.