Request For New PAN Or/And Changes Or Correction in PAN Data

Only Only
'Individuals' 'Individuals'
to affix recent to affix recent
photograph photograph
(3.5 cm * Permanent Account Number (PAN) (3.5 cm *
2.5 cm) 2.5 cm)
A V X P N 1 5 1 5 B
Please read Instructions 'h'&'i'for selecting boxes on left margin of this form.

Signature/Left thumb impression

CSF - Application/Coupon No.:U-MC00224761
across this photo Payment Ref.No.YHMP1706238891& Amt : Rs.71.90

þ1documents:
Full Name (Full expanded name to be mentioned as appearing in proof of identity/address
initials are not permitted)

¨
Please Select title,
þ ¨ ¨
as applicable
¨
Shri Smt Kumari M/s Signature/Left Thumb Impression

Last Name/Surname K U M A R V E L U S A M Y
First Name N E E L A K A N D A N
Middle Name
Name you would like it printed on the PAN card
N E E L A K A N D A N K U M A R V E L U S A M Y

¨ 2 Details of Parents (applicable only for Individual applicants)

Father's Name(Mandatory. Even married women should fill in father's name only)
Last Name/Surname K E T T I S A N K A R A L I N G A M
First Name K U M A R V E L U S A M Y
Middle Name
Mother's name (Optional)
Last Name/Surname K U M A R V E L U S A M Y
First Name G U R U V A M M A L
Middle Name
Select the name of either father or mother which you may like to be printed on PAN card (select only one)
(In case no option is provided then PAN card will be issued with father's name) þFather's name ¨Mother's name (Please tick as applicable)

¨ 3 Date of Birth/Incorporation/Agreement/Partnership or Trust Deed/ Formation of Body of individuals or association of Persons

Day Month Year
2 8 0 8 1 9 9 3

¨ 4 Gender(for 'Individual' applicant only) þ Male ¨ Female ¨ Transgender (Please tick as applicable)

þ 5 Photo Mismatch
þ 6 Signature Mismatch
¨ 7 Address for Communication þ Residence ¨ Office (Please tick as applicable)

Name of the Office (to be filled only in case of office address)

Flat/Room/Door/Block No. 4 4
Name of Premises/Building/Village S I V A N W E S T S T R E E T
Road/Street/Lane/Post Office V E L A N K A N N I
Area/Locality/Taluka/Sub-Division K I L V E L U T
Town/City/District N A G A P A T T I N A M
State/Union Territory Pincode / Zip code Country Name
TAMIL NADU 6 1 1 1 1 1 INDIA
¨ 8 If you desire to update your other address also, give required details in additional sheet

þ 9 Telephone Number & Email ID details

Country code Area/STD/Code Telephone/Mobile number
9 1 9 1 9 3 6 0 4 6 5 1 9 6

Email ID neelau2@yahoo.com
¨ 10Name
AADHAAR number (if alloted)
as per AADHAAR letter/card
4 2 0 8 7 5 2 1 4 0 1 2

N E E L A K A N D A N K U M A R V E L U S A M Y

¨11 Mention the Permanent Account Numbers (PANs) inadvertently alloted to you
PAN1 PAN2 PAN3 PAN4
12 Verification
NEELAKANDAN KUMARVELUSAMY HIMSELF/HERSELF
I/We ,the applicant, in the capacity of do hereby
declare that what is stated above is true to the best of my/our information and belief.
I/We have enclosed 1 (number of documents) in support of proposed changes/corrections.
Place VELANKANNI
D D M M Y Y Y Y
Date 3 1 0 1 2 0 2 3
Signature/Left Thumb Impression of
Applicant(inside the box)