ALIN 1 ‘Assessing officer (AO code) Form No. 494 ‘See Rule 114 Application for Allotment of Permanent Account Number Lin,the case of indian Citizens! Indian Gompanies/ Entities incorporated in Indie! on Unincorporated entities formed in india) CAO seis tian sn io anor arto ros oe ng eo ‘area code, ‘AO type Range code RO Ne. fc tx Tn [w e [1 1h, We hereby request hat a permanent Aecount Number be ated to me/us. lowe give below necessary particulars: Full Name (Full expanded name to be mentioned 8s aj aring in proof of identi ‘Application Source: JApplication Date:[13/01/2023 User la(615331460015 | User Namo:[ PAN CARD MODE : Both physical PAN and e-PAN Card [Application Mode : Physical Applice HATH MCN Pease sit ita [Jan acpicane [v]som | Jsme—[__]uman LastName / Sumame PlAlr[AlAlal J FrsiNane R/A|J/E/S/H Made Name KUMAR Abroviation ‘name, as you would tie tt be printed on Rae KUNAL PIAIT[HIA[K ave you ever Been known by anyother name? ves [no (please tek as appiicbie) ye, ae hth eave Poooo solectte,|V Jac appicatte [sti [st [Jura [Jos Lost Name Sumaine Ty ] Frat Name | eal o t | 4 ‘Gonder (for Individual appicants cniy) Date of Binthiincorporation/Agroement/Partnership or Formation of Body single parent and you wish to app for individuals or association of Persons ieable only for individual applicants), ‘Trust Deed! PAN by’ umishing he name of your mother only? Yes| tyes, please dln motners name inthe appropriate space provided below. Monts |Tranegender (please tick. Gis) (ofS) G [ele[s applicable) No [7] (please tk as appicabl) Fatnco's Name (ondatary except whee mutes sng parent and PAN e applied by furising tre name of mothe Lasitene Sora PlAlT [Halk I J First Name JSIAIYISIALY. i Nidal Nine RIAIM i Mothers’ Nar (optional xcept where mothe i aed FANT app by RAHI name moter ony) Last Neme/ Sumame ] Fist Name 4 Migsle Name [ TI Tt [ J Salt be neo eter ator mabe iS ny We bs ped Or FAN er ooo (incase no option is provided then PAN card wil be issued with fathers name exce PAN by furishing name of the mother eri) [7] Father's ame Address ep! were mother i a single parent and you wish to apply for ati Residence Adeross Flat/ Room / Doar! Block No, Noro ot Promiea Buiing Vitogo — FELAILT LK Rca See LanePost Otce DiUBlAvUIt Ti [oly fea /Cocy Toei Ovi (BTATSITITL | “bre Goya + a State / Union Teetory ‘County Name UT 1 El N- DN tla Lr Ae Name of fice Fa / Roam /Deot / Block No, ‘ame of Premios / Budding’ Vilage‘ea | Locality! Tlokal S- Division “Town / Cy Distt [ Aadres tr Comunteation Teleco Number & Ema 1 deta | Country code Arsa/STD Cove Teiephone / Mobile number 3]t [ tp Eberle! LL Emaiito (fd. gotwa@gmai 10 Status of applicant select status, ‘com. a Techie ren [dein othe Loleccaautorty Jari rin Persons [] mies iit Pare 1" 12 Gase ofa parson, who Ie equred to quo AahaarsumberThe Enrolment Oot Aedhear Toi ae per sction 19988 eave manion our AABHAAR mumber(t aoted) [ST [317] [51] 8 [4] [SIs] 219 8 WAADHAAR numbers aot allotted, please mention the enrolment ID of Aachaar application for ‘orm Name as per ADHAAR leterfcard or as per the Enroiment 1D of Aadhaar application A | RIATJTeE[S[H Ku ale PIA T HI AlK | 43: sours ottncome Pease seed, [¥/] ee appicble | Elsa Tit ere Fastin — [cope | woioeneuess/Petusen sinners cate [-[_] Foca: retrrenstin [1] icnetom ones 4 Representative Assossee (RA) || Fullname, address ofthe Representative Assessee, who is essessible under the Incorne Tax Act in respect ofthe person, whose particulars have ‘been given inthe column 1-13 Fohace Sande too Poesia [7|osotons [Jem [Jam [Jiaman [Jum satin tesa [ First Name Midge Name Address Flt Room / Door / Block No. Name of Premises / Buiaing Vilage Road / Street Lane/Post fice ‘Area ( Locaity!Taluka/ Sub- Division I Town (Cty Distet ‘Stato / Union Tory em. Bie |_JPinceoe 18 Documents submited as Proot of deny (POH, Proof of Address (POA) and Proof of Date of Binh (008) |e have enaoses [~ AADHAAR Card U6 BY —] x root orient, ese spoof assess ana [AADHIAAR Card esu6d By UIDAT | a poo of dat of bith [Prease rofer to the instructions (os specified in Rule 114 of LT, Rule, 1962) for list of mandatory cetiied documents to be submited a8 appcabe) [Arcenire A, Annenure 8 & Annexure C are to be used wherever applicable] | st vwe(RAJESH ROMER PATHAK” ~~], naps nt capaci ot [FINSELFTMERSELF ‘do hereby declare that what is stated above is tue tothe best of my/our information and boi Place BASTI SRT SUE NES san Ta gad Ra sa