Annexure -A (Certificate tobe used by a Member of Parliament/Member of Legislative Assembly / Municipal Councillor or Gazetted Officer under sub-rule (4) of rule 114 of the Income-tax Rules, 1962) fisane ‘Photograph as Med on PAW ication fr THe Be asd iy suing” authority with disher signatre & robber samp appearing half on the photograph and half om the certs) muKum... I hereby certify that | know Shy pesca pesca ..and his/her personal particulars as given son/daughter of .. ee below are correct to the best of my knowledge and belief. | recommend issue of PAN card by the Income-tax Department to him/her. Name Father's Name (even in case of mare ladies father's ‘name i to he provided Date of Birth Residence Address aided at more than ne year then Office Address Previous Name (incase of shane in ams Details of issuer of certificate (Signature) Office address with location Full Name: Designation: Office Seal Department/Organisation/Constituency Identity card No. Mobile: IMPORTANT NOTE : Fot Major Changes / Correction in Name or Father’s Name of Applicant, this certificate in Original is Mandatory for PAN Application. Certificate can be attested by any Gazetted Officer /MP/ MLA. / Municipal Counsellor. Along with ‘Annexire A, photocopy of Govt Office ID Copy of the Officer who Avtests this Certificate is Mandatory.