Form No. 494 Application for Allotment of Permanent Account Number nthe case of indian Citzensfindan CompantasEnttesncorpersted in India! ef Pp Unincorporated entities formed in india} ers Seon ‘oats ane el eer Assessing officer (AO code) ‘aacode | AD ype | Rangecode [AO We IK[A|R|W 4 2[ aot F W]e herby requne at peonanat account uber e ed mahi. a iii ies ton roceieny paar Ven) ef ey 37H an ied man bs appa a RST ps Ditaddrese documents: nti ae not parte) Please sooctite,[V Jas appicabie [_]sini se. umari Jews Last Name / Sumame. 7 Feat Name le Name a ae eee Please setect title, | ¥/| as applicable Shi wis. cae pacts Middle Name i a acpes eripmaipaac sek 2 uae IRR RETA a ste ona Se ee aaa ofa) [0/2] (a/9/514 6 Details of Parents (applicable only for individual applicants) her ape isa single carent and you wish to apply for PAN by furshina the name of your ther only? ves [¥ ]no (nease tek 08 appcabia) res, in mother's name inthe appropriate space provide below. Father's Name (Mandatory except where mother is a single parent and PAN is applied by furnishing the name of mother only) ‘Last Name /Sumame H/A|N|U|M/A/N)T/A[P|P/A, Fist Name Muscle Nome Mother's Name (optional except where mother is a single parent and PAN is applied by furnishing the name of mother only) Last Name / Sumame Fst Name Mite Nome ect the name of. x mother wich yu ay he ob pried on PAN card (Selec one on | hers name Mater name (Please tick a8 applicable) {incase no option i provided then PAN card willbe issued wit father's name excep where mothe i singe parent and you wih fo apply for PAN Sy fomsehing'name ofthe mother only} Be Se 7 Aatdcoss: Residence Adaress Fat / Room /Opor/ lock No. Name of Premises /Butking / Vitage Road / Steet /LanerPost Offco ‘Area Locality Taluka! Sub- Dion Town / City / Dist ‘State / Union Terory Pincode !Zip cose ‘Country Name FaReraRa 5[8[3/2/2{e| | mom J9 Telephone Number & Emall ID detalls 0 2 a “ 16 6 ‘Office Address, = Name ofoftce Fiat/ Room / Door / Block No. Name of Premises Building! Vilage i Road / Steet LanePost Ofce ‘Ara | Locaty | Taluka! Sub- Division “Town / ity /Distiet i State! Union Teentory ‘Address for Communication Country code Ave (Please tick as applicable) +/9/1 met to sta of appcant ‘uae sect stan, [7] on aplcabe vant pees of Perera penne |] tite Listy Parenti {Im case of a person, who is required to quote Aadhaar number or the Enrolment ID of Aadhaar application form as per section 129 AA Please mention your AADHAAR number (f atiotted) [20/0 [1 [7 HTAAOHAAR number i no alloted, please mention the enralment ID of Aadhaar application Name as per AADHAAR letter OF card OF a5 parte Er slalv|t/T/R/A[M, Source of Income Salary ‘Income trom Business / Profession Income from House property ‘Representative Assessee (RA) Business/Profession code Full name, address ofthe Representative Assessee, who is assessible uncer been given inthe column 1-13, Full Name (Full expanded name : initials ae not permitted) Pease sett te [Van sorense f]smi [Jom Cherm 6/0/98 /6/8 a Dtee ‘A T Please select [v7] as applicable _) coptai Gains {For Code: Reterinsiuctons) ¥7] Income rom Other sources [7] vemncome the Income Tax Ac in respect of the person, whose particulars have LastName /Sumame i Fret Name dale Name Address Flat / Room / Door / Block No. Name of Premises! Bung /Vitage Road | Steet /Lane/Post Office | ‘Arwa / Locality / Taluka! Sub- Division Town | Cty / District ‘State / Union Terrtory Pincods. Documents submitted as Proof of Identity (PON, Proof of Address (POA) and Proof of Date of Birth (POB) We have enciosed [AADHAAR CARD ____} as proof of entity, 88 proof of address and [AADHAAR CARD £0 proof of date of bith. {Prease refer to he intructons (as specified in Rule 114 of. Rules, 1962) frist of mandatory cerifed document to be submited as apptcabe] (Annexure A, Annexure B & Annexute C are tobe used wherever applicable Wwe[SAVIERAMMA___________], the aoplca,n tho capecty of [HERSELF] ‘do nereby deciare tat what i stated above ls rue 16 the best of myfour information and belie. Place KOPPAL Seetacocsele! Gab sox, / Enrolment No 2017/91519/69655 | Te, mos, Scuarna Wo: Aninappe tiger | agar rebepana! Koppe Kop | ‘savanois Kemah 562228 Ff 1842 288 5200311526188) ab, eq0® Boal, / Your Aadhaar No. 2001 7060 9868 185, 25008/ 008 010171054 3 Female 2001 7060 9868 SOROS’ - Semoawa,S vhesod ort AADHAAR abs © emnot ibaa aundabe atodeh ogg . Ae rhea madeabaldalen, oaF Ty choos peda. INFORMATION ® Aadhaar is proof of identity, not of citizenship = To establish identity, authenticate online 1 eqw0F dedendjos area soba, 3oOS | oa,d0, Sear morte aarcead aectrivng, | Bdoben eqao! Adht Sanobéaariod ‘Aadhaar is valid throughout the country '= Aadhaar will be helpful in availing Govemment | ‘and Non-Government services in future 59 526004 Ay. Smtiasoenee ZY aria taentincation Authority of india vac ich ade oatseh Adress: NO: Aninappa ger, ‘Gormo, soy krrimov. lanai, Hrebaganal, Koppa Gedy. doaly. sword. 220 Koppel Kamaiska, 583228 2001 7060 9868 3 a =