Application Number: A039414307

Application Number Bar Code Payment Reference: 1151125523311297 / PY0049490447 Inward Number Bar Code
Payment Date: 31/05/2021 Rs.107.00/-
Application Source: EWALLET - A - APNA-CSC Application Date: 31/05/2021
User Id: 213221370011 User Name:

PAN CARD MODE : Both physical PAN and e-PAN Card Application Mode : Physical Application

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P U S H P A
G O R A K H

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Whether mother is a single parent and you wish to apply for PAN by furnishing the name of your mother only? Yes No ✘ (please tick as applicable)
If yes, please fill in mother’s name in the appropriate space provided below.
Fathers’s Name (Mandatory except where mother is a single parent and PAN is applied by furnishing the name of mother only)
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S I T A R A M
S H I V A
Mothers’s Name (optional except where mother is a single parent and PAN is applied by furnishing the name of mother only)

(In case no option is provided then PAN card will be issued with father’s name except where mother is a single parent and you wish to apply for
PAN by furnishing name of the mother only) ✘

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ingaleb007@gmail.com

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P U S H P A G O R A K H R A N D I V E

AADHAAR Card issued by AADHAAR Card issued by UIDAI

UIDAI (In Copy) (In Copy)
AADHAAR Card issued by UIDAI
(In Copy)

PUSHPA GORAKH RANDIVE HIMSELF/HERSELF

RAJURI

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