Application Number-A040206598

Payment Reference: [1179135326705643/PY0050629630

JPayment Date: 28/06/2021 Rs.107.00/-
pplication Source: EWALLET - A-APNA-CSC |Application Date:28/06/2021
Jser Id: 211222430015 JUser Name:
AN CARD MODE :Both physical PAN and e-PAN Card Application Mode:Physical Application
Form No. 49A
Application for Allotment of Pemanent Account Number
[In the case of Indlan Citizens/ Indian Companies/ Entities incorporated in India
Unincorporated entities formed in India]
See Rule 114
To avoid mstakes. please follow the accompanying instructons and examples before filing up the form

Assessing officer (AO code)

Areacode AO type Range code AO No.

B P L |WIT8|5|||4
Sir, IWe hereby request that a permanent Account Number be allotted to me/us.
We give below necessary particulars:
Signature/Lot Thumb Impression
1 Full Name (Full expanded name to be mentioned as appearing in proof of identity/address documents:initials are not permitted)
Please
selecttite.as applicablex Shri Smt Kumari Ms
Last Name Sumame
B A GHEL
First Name
D AMR U
Middle Name

Abbreviations of the above name,as you would like it, to be printed on the PAN card
D A MR|U B A |G |H|E|L|

Have you ever been known by any other name?

yes. please give that other name
Yes No
HHHHHHHHHH| (please tick as applicable)

Please select tite. as applicable

Shd Smt. Kumari Mis
Last Name / Surnamne
First Name
Middle Name

Gender (for Individual applicants only)

Male Female Transgender (please tick as applicable)
Date of Birth/incorporation/Agreement/Partnership or Trust Deed/ Day Month Year
Formation of Body of individuals or association of Persons
Details of Parents (applicable only for individual applicants),
Whether mother is a single parent and you wish to apply for PAN by fumishing the name ofyour mother only?
If yes, please fil in mother's name in the appropriate space provided below. YosNo (plsase tick as applkcable)
Fathers's Name (Mandatoryexcept where motheris asingle parent and PAN is applied by furmishing the name of motheronly)
Last Name/ Surmame BAGHE L
First Name
D AM R|U
Middle Name
Mothers's Name (optional except where motheris a single parent and PAN is applied by furnishing the name of mother only)
Last Name / Sumame

First Name
Middle Name
L
Select the name of either father or mother which you may like to be printed on PAN card netecsone onb
(In case no option is provided then PAN card willbe issued with father's name except where mother is a single parent and you wish to apply for
PAN by fumishing name of the mother only) x Father's name Mother's Name (Pwe tick as upplkubke)
Address
Residence Address
Flat/ Room/ Door/Block No. SOsANPALL KE SHILO oR
Name of Premises/ Building/Village SOSAJN PALL
Road /Street / Lane/Post Office T o KA PAL
Area/Locality/Talukal Sub- Division KE SH|Lolo R To K[A P A
Town/ City/ District B A S TA|RI_I
State/ Union Territory Pincode Zip code Country Name

CHHATTI SGARH 4 9444 2 | IND IA

Office Address
sTETTHTTYATTclHlolT lcTET TCTETNITIFTRTTT
 Area Locality / Taluka/ Sub- Division
ToK AP ALBAS TER
Town City / District
BIASTA, R LI
CHHATTISGARH 4 9 4 44 2 NDIA
8 Address for Communication
9 Telephone Number & Email 1D details xResidence office (Please tick as applicable)

Country code Area/STD Code Telephone / Mobile number

Email 1D aryansethiya7354@gmail.com

10 Status of applicant

Please selectstatus, as applicable

Government
ndwidual Hindu undivided family Company Partnership Firm Association of Persons
Trusts Body of Individuals Local Authority Artificial Juridical Persons Limited Liability Partnersh1p
11 Registration Number (for company, firms, LLPs etc.)

12 In Case of a person, who is required to quote Aadhaarnumber/TheEnrolment1Dof Aadharapplicationform asper section 139AA
Please mention your AADHAAR number (if aloted)
690 9485 47 0 1
If AADHAAR number is not allotted, please mention the enrolment ID of Aadhaar application form

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

DA MRUL BAGHELL

13 Source of Income
Please select. | as applicable
Salary XIncome from House property No income Capital Gains
Income from Business/ Profession
14 Representative Assessee (RA)
Business/Profession code F o r Code: Refer instructions] Income from Other sources

Full name, address of the Representative Assessee, who is assessible under the Income Tax Act in respect of the person, whose pariculars have
been given in the column 1-13.
Full Name (Full expanded name : intials are not pemitted)

Please selecttite.as applicable

Shi Sm Kumar Ms
Last Name/ Sumame
BAGHE L
First Name
DAMR U
Middle Name
Address
Flat/ Room/ Door/Block No. s OS ANPAL|KE SH R1
Name of Premises / Building/ Village
SosA NPALLL
Road/ Street / Lane/Post Ofmice
ToKAEALL
Area/Locality/ Taluka/ Sub- Division T oKA P A L BA S TAR
Town/City/ District
BASTAR
State/Union Territory C H HAT T I S G A R H 4 944 4 2Pincode
15 Documents submitted as Proof of ldentity (POI), Proof oft Address (POA) and Proot of Date of Birth (DOB)

iwWe have enclosed AADHAAR Card issued byas proof of identily AADHAAR Cardissued by UIDA
as proof of address and AADHAAR Card issued by UIDATa s proof of date of birth.
Please refer to the instructions (as specifled in Rule 114 of IT. Rules, 1962) for list of mandatory certifed documents to be submitted as applicable
Annexure A, Annexure B & Annexure C are to be used wherever applicable
16 IWe DAMRU BAGHEL the applicant, in the capacity ofHIMSELFIHERSELF
do hereby declare that what is stated above is true to the best of my/our infomation and beliet

Place JAGDALPUR
 mmeto
Damru Baghel
aF fart/o0B:01/01/1994
TT/ Male

6904 9485 4701

3HTETT 3H1A 3TGET HTQR

Uniue horly oftndia

: S/0: gana rdz, ataa Address: S/O: Sukhman Baghl, sosan
pal, keshlur, Panchayat keshlur, Keshloor,
Bastar, Tokapal Rajoor, Chatisgah
BFeirene, 494442 494442

690494854701
www

1800300 1947 help@uideigow.in www.uldal.gow.