Form No- 49A

Application for Allotment oI Permanenl Account Number

ln the case of lndiaB Citizens/lndian Companies/Entities incorporated in India/
Unincorpotated entities formed in lndial
See Rlle 114
io a'o:d m,siale 1s) olesse los lhe rcmdratvrnq nstiocrioos 3nd elanrdes belote nl:Jng ut! the ,ornr
'!
Assessing officer {AO codel

AO type Range code AO No

K A R W 1 2 4 5
S,r
irWe hereby reeLiesl lhal a permaner I accouol nLrmber be allolted to melus
lrl^re q ve b€lovr necessarv paallcLrlars.
'1 Full Name (Full expanded name to be mentioned as appearing in proof of identity,/date ol
birth/address documents: initials are not permitted)

Please select tirle.

Last Nane / Surname

lY ] as applicable
KA R
Sh.t
n
I YAI A
Smt

H
K{rmari
['r,.
First Name
Middle Name
2 Abbreviations at the above name, as yoo would like it, to be printed on the PAN card

KA R I Y A I A H
i

3 Have you qvor boon klrowd by any othor nam6?

llyes pleasa give lhal other name
fl,* No lplease tick as applicable)

Please selecl lltle. as applicable Shri Smt Kumari Mrs

Lasl Name i Surna,ne I

F rst Name

[rlddle Nanre

4 6ender {tor Individual applicants only) Male Female I lrrnre"nd", {please tick as applicable)
5 Dato of Birth/lncorporation/AgrsementiPartnership or Trusl DG6dl Formatlon of Body of individuals orAssociatlon ot Plrsons
oay Monlh
m
Yoar

@ 1 1 9 5 0
6 Detalls ol Parents (applicable only lor individual applicants)
js a sinqle oarent and you wish to aDplv tor PAN bv furnishinq lhe name ol Your molher oniv?

ffv.:ffir o (please lick as applicable)

il yes. please lrli in molher's name in the appropriate space provide below.
Fath€r's Name (Mandatory except wher€ mother is a single parenl and PAN is appliod by furnishing lhe name ot mother only)
--l
Last Name / Surname c H I K KA R AN G A I A Il I

First Name
lviddle Namo
Mother's Name (optlo nal except wher6 mother is a single parent and PAN is applied by furnishing the name ot mother only)
Lasl Name / Sumame
Firsl Name
Middle Narne
Select the name of ei ther lalher or mother which you may like lo be pinled on PAN card (Selecl one only)
f]Mo,nur'. nnr" IPt;ase trck as apphcabte)
(ln case no option is provided then PAN card will be issled wilh father's name excepl whore molher is a single parent and you wlsh lo apply {or PAN
by {urnishing name of the mother only)'
7 Addross
Residence Address
Flal / Room / Door / Block No. J o K KA RAN G A
c H I I A H
Narne gl Prenises / BLrildrng / Villag6 A E RE RAMA ARA
Road / Slreel / LanelPost Oflice c H I K K A, B D A R E P o H U L I YAR H o
Area / Localily /Taluka/ Slb' Division C H I K K A N A Y A K A N A !1 A t L I T A L u K
TownlCity/Dislrict T U M A K iun u
Stale / Union Territory Pincode / Zip code Country Nanle

KAFGWMTG 5 1 2 212 8 I aou,

 t
Office Address

:TI -T-[
Narne of office

_T_[I t-r-tT
Flat / Room / Door / Block No.

ffi
I

l=T-frl --r- Tfr t-f

I
Nafie of Prernises I Euilding / Village
Road / Stre€l / LanelPosl Office t- t l
Area I Locality / Taluka/ Sub- Division
TowniCity/Distrlct
State / Union Tenitory
Itl Pincode / Zip code
T Country Name

8 Address for Communicaaion Residence Office (Please tick as applicable)

I Tolophone Nlmber E EmaillO dotails

Cauntry code ArealSTD Code Telephone I Mobile number

+ 9 l- I l8 8 6 1 4 5 I 9 9 6
Email lD

{0 Status ol appllcant
Please select status. V as applicable Government

lodividual Hindu undivided iamily tr Company Ieartnersnio

rrrm Association ot Persons

Trusts
11 Registration
Body of lndividuals
Number (for company, firms, LLPS etc.)
il Local Authority
In*tttat Luridical cersons Limited Liability PartnershiP

Tl-Tt I I

12 ln case of a person, who is required to q!ote Aadhaar number or the Enrolment lD of Aadhaa. application folm as per sectiod ,39 AA
Please mention you.AADHAAR number (it allotted) 7 9 0 2 2 9 7 2 9i1 I 3
lf AADHAAR number is not allolted. P lease mention the enrolment lD oiAadhaar application forrn

Name as pe TAADHAAR letter gr card or es P er lhe Enr0lment lD ofAadhaar a

ll
K A R I Y A I A H
!

13 Source ot lncome P/ease serect, a€ apqlicable

CapilalCains
Salary
lncome trom Business /
lncome arom House prope.ty
Profession Busjness/P.ofession code II [For Code: Refer insiructions] lncorFe ,rom Oiher sources
No income

l4 Representative Assessee (RAI

F ull name, add ross ol the Representative Assessee. vnho is assessible under the lncome
Tax Act l0 respect of the porson whose particulrrs have
been given in the column 1'13
Fult Name (F!U expanded name : inltials are not pennitled)
Please selecl title, as aPPlicabl,A Shri Smt Kumari [4ls

Last Name I Surname

lTTrl ----r---
l-.|--frl
First Name
Middle Name
Address
fr T- I
I

-T
ffi
Ftat I Room / Door / Block No,

t- ll -l--i-
Name of Premises I Building / Viilage
Road I Street I Lane/Posl Office
Area / Locality / Talukal gub- Division
rIlI
TownlCity/Dislrict -T-
State I Union Tenitory Pincode

15 Documents submitted as Proot of ldentity (Pol), Proof of Address (PoA) and Proof of Date of Birth (PoB)
llwe have enclosed AADHAAR CARD as proof o{ idenldy. AADHAAR CARD
as proof of address and AADHAAR CARD as proof of dale o{ birth.
l
lPlease refer to lhe instruclions (as specilied in Rule 114 of I Rules, 1962) for list of mandatory certifled docufients
to be submitted as applicablel

JAnnexureA. Annexure B & Annexure C are to ile used wherever appljcabie]

16 l/We KARIYAIAIT , the applicani, in the capacily oi ITIMSELF
do hereby declare that what is slated above ls true to the besl of my/our information and belie
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draeodsd ioer/ Enrolme nt No. i 2906/04645/03554 !NTGEMAfION
. Aadhaar is a proot ol identity, not of citizenship.
tGriyaiif
slo Chjkr€.anqa,ah
r Veriiy identity using Secure OR Code/ Ottline XMU Orrine
Authentication.
r Tnis is electro'1ically gererateo letter.
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aAdd.Da. C,8d(6Rf irdi

r Aadltaar is valid throughout the couotry

. Aadhaar helps you avail various Government
and non-Government services easily.
Je$ 6 ejr;acr / your Aarjhaar No-
adoard . Keep your mobile number & email lD updated
in Aadhsar.
709 2 9 22 9 1 8 73
VID 9 4 6 03 3 6 5 )
5 35 1
. Carry Aadhaar in your sma phone-use
;J .J ;J r! dJ mAadhaar App.
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Government of lndia tll u.d&cd, ale ri,(j)d) slQrjd
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1-"- Uaioue tdenftcatron Autnonty ot tncra
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5/O Chil*arangalah, a\,?iagere, ramanaqara,

KarnatalG - 572228

7092 9229 7873

7092 9229 1873
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