u -Q007331 l AE

l]flililtilltililiilil IilII
Qroo_7=311-45
"rr -:-:': a a-!a
I -tll a
u ser ro:i6662655600 - 2

6
Applical c- s:--:= -rLE- - - - ,
-rr : :l'. --: :-:AN Card

Request For New PAN Card Or/ And Changes Or Correction in pAN Dala
le pplicar,o-v::' I- - ,' -,, -t,
AIa ar.
::
\I

r: irs:|! Permanent Account Number (pAN)

--_-
t GBZPK 5 8.8 2lC
- f
neese reaC lnstrlrct;ois h A ;or ietealrng tloxes
on lefi margirl of this ,a,-
'se,eUntrt
sat*dtco"r
I
I

tr 1 Full Name {F:-

documents. n
e'i.1ded
: -..r;
oame to be menlioned as appearing in p.oof ol identity/address
not permitted
$r.l T't-'*',....,-., --

Last llafis / Sura[D€ K U M

x Shri
T Smt Kumari

First Name tr J I T
lriddl€ t{ama
Narne yoL r,/oLrtd rke rt printod on the pAN card
AIJ IIIT] IK iU l\/l R

2 Detar s of PJrents lappl;cable oflty for individual apptrcanrs).

x Falher's Name : (lrandatory, Eien married woirien shoL ld fill in father's name onl v)
Last Name / Surnarne M nlruloleLl
First Name
iriddle Name
L_l
R U N
tlt
l
I
Mother's Narne (optional)
Last Name I Sumame f-r-r
Firct Name
[/tiddle Na,ne
Se'ect the name ot either father or mothe ch you may like to be printed on pAN card a.1.,r.r,",r,)
(ln case no option is provided then pAN card will be tssued with father's name)
x ,\,1olh6r's Name ptua:t titi.\ qph.$t..j

n 3DateofBi(hrlncorporation/Aqreemcnt/partnershiDlTrustDeod,
r ormdtion of Body of individlats or Association bf persons
uay,
p 6
Morth Year
FlrTsr--l m
T
i

4 Gender {for'lndivid ual'applicant only) ,l Male

x 6 Signatue Mirmatch
r.."r"
x 7 Address for Communication
Transgendor lr,r.n* krns,ppr,.,br.
,( Residence Office
ff lI
,( 5 Photo illsmatch
lPrc.$c ktr\ ipr:,.rllln
Name of Office no * ru
FlaYRoom/ Door / Block No

Name ot Premises/ Building^/iltage

4.4
H R N
AIci[l*
AR Y
M

N
N

P U R
D L tll=Tr
Road/St.eet/ Lane/Post Office L Hln uln A i

Area / Locality /Taluka / Sub- Division JA MU I

Town/City/District JA tuu I I

Eg_telqn'g!_re4!qry Pin.ode I Zi CoLrolrv Name

IHAR 8.1 13 0 7 iINDIA
8lf you desire to update your other adclress al9o, give required details ln addiiionat sheet
S letenfrone t'tumber & Emart tD detarts Countrv cod € A.ea/STDrCoda Telephone / Mobile ntirmb6r
I
Email tD
91 r EIITITTT fo slsisizi+ IE-mil:n
tr t0 AADHAAR number (if attotted)
Nar e as pe.AADHAAR telter/card
|
-a___
l
AJ T I I T-T
t
1

I tt uention other permanent Account !tr-'ffi rrr-ril-r tt

Ns) insdvertentty atlotted to you
---r-

PAN 1 GB ZP K5 8 8 2 C PAN 2i PAN 3

12 Verification
IT KUI\4AR , the applicant, in the caPacitY of HIMSELF/HE ELF
do hereby declare lhal what is stated above is true to lhe best of my/our in{ormalion and belief.
l,IWe have 3 (numbe. of documents) in support of proposed changes/cofiections

Place

Date 1 '1
1 2 2 0 2 2
Signature / Left Thumb lftpression of (inside the box)

\
 .!'), tm-&q ftfarsr q:6n1a qrRY$rEr 6r\
Unique ldentification Authority of lodia
+' rrra +ra6rr .A',
C:1 Government or India
316"r isc, ,q Era1]qqE{ *€ nt{r, e{i,
3166 grcR 811307
Ajit Kumar
irir Rft/mB: 06/01/1986
56q/ tlArf

2s3s 1191 3380

2535 1191 3380 6I E @)

qtraFr

(1t\$,r.'^-*-'ta-

.r(

{'
eirqft( fu{rq }Irt-et ({.Fr{
INEOMITAX DEPAXf,MENT :.: GOYI, OFINDIA
rErff tsr drgr m€

ffi
AJIT Kt' AA
Permanort Aacounl NumbQr oard

GtsZPK5882C l

I
fuii 6r ?lc,I Fdh.r's Nam.
ABUN KUIiiAR }IANDAL I

g* * sit{i r 0*}61!fih I
06/0 tri986 '' ' 3

Sr r!Pta*"-*u-
 li;:! ..*;'3i(

E
i r:t., t,

; ..1
'.';1: ll

|-

,,"-i r!*..... i

a.l