|Application Number:|A060185591 1 UU IM IN]. rere enone, 825207528657065 [PYOTTT2OSHRD 09/09/2023 Rs.107.00/- SS 52 + Jpaymont Date: User id:[WB153500376 —__|Usor Namo: BAN CARD MODE : Both physical PAN and e-PAN Card Form No. 494 Application for Allotment of Permanent Account Number {tn the case of Indian Citizens! Indian Companies! Entities incorporated in india ‘Unincorporated entities formed in india] ‘See Rue 14 ‘Assessing officer (AO code) or Trea code | nOiype | Range cogs [AO Wa 3 Have you ever beon known by any other name? yes please ove that ther name eae sete [7 ]exapocane Last Name / Sumame FestName cde Nae Bele le 46 Gonder fo icividual appicants ony) [lite Eehrmate [pit tt te 5 Dats of BitvincorprationAgreomentPartnrship oF Trust Deel a Formation of Seay ofindviauls or aneccation of Persone fois) (073), [Isola] {6 Detaits of Parents (applicable onl for individual applicants) \Wnether mothers a single paren and you wish o apply for PAN by furishing the name of your moter only? Yes[_] ifyes,ploase fin mothers name in he appropriate space provced belon. Fathers's Name (Mandatory except where mothor isa single parent and PAN is No [7] (niease tck as applicable) ‘Last Name / Surname Mit lY IA First Name PLiYIAIR Middle Name MIA|H|A/M M/A[D Mothers's Name(optional except where mother i Last Name / Sumame Lid First Name l Middle Name La ‘Select the name of ether fathor or mother which you may ike 0 be printed on PAN card rie an wa) {nomen opton le povidod ter PAN cer wi be eeud wih herr except whee moter sgl parent and ou wah apply Febererame [[_]Mathers tae romps PAN y fumishing name of the mother only) [7 Address: Residence Address Fiat! Room / Door / Block No. fe Name of Promisas/ Buiing / Vilage Road / Street /Lane Post Oice ‘rea | Locaty/Taukal Sub- Dhsion Town / City / Distt URE. State / Union Teitory Pode 2p te WEST BENGAL | ‘Country Name Office Address Name of ofc Flat/ Room / Door! Block No. l Name of Promises Buking / Wage EEE Rood /Srst /Lane/Post Offente CEE EEE oie EEREEEH 8 Address or Communication 8 Tetphone Number & ial ID dette County cote ArealSTD Cooe a1] (elsisl2[2 B | Government Cleomeany [Doe atininaie” + Jeary 1 Registration Number (fr company rms, LLPs etc) Lpstreairim Aone Pea [ste arises Pomona, Parrot ml LI ii Ears 12 In Gase of a person, who is required to quote Aadhaar numberiThe application form a por section 139A Pease mention your AKDHAAR number (f allotted) [2 [9 [4 | 6 of 3) AADHAAR number's no alloted, please mention the enrolment 1D as [Name as por AADHAAR jtlricard or as per the Enrolment ID of Aachaar application form yIO} J T[SINJA] [KJH[A[T[UIN] [8] te] i] | 13. Source of income LL] somy Clic ntocainpety [Ee] een achat Satna ct 14 Representative Assessee (RA) Fullname, address of the Representative Assessee, who is assessile under ‘boon given in the column 1-13. Full Name (Full expanded name : initials are not permitted) Peoee ste ite, [7 ]aeapteable Last Name / Suame First Name Midale Name Address. Fat Room / Door / Block No, Name of Promises / Bulaing / Vilage Road Steet /Lane/Post Office ‘Area! Locality /Talukal Sub- Division Town City Distt | State / Union Terry 15 Documents submitted as Proof of Identity (POI), Proof of Address (POA) and Proof of Date of Birth (D08) RADHAAR Card issued BY | a prot of ent. issued by UIDAT ss prot of adress ana [AADHAAR Card fesued by UIDAT | 9g soot of date of bith (Please refer tothe insrucons (a8 speci in Rule 114 of 17. Rule, 1962) for lat of mandalory ceed documents to be submited as apples] [Annenure A. Annexure 8 & Annexure C ae to be used wherever applicable] 16 Wwe |. the applicant nthe capacty of AINISELFIAERSELF «do horoby dectare that what is stated above is rue tothe best of my/our information and bole. DoMM ofsfole oueel oa ‘Signature Leh Thumb impression of Applicant (inside the box)1 @ ores ANT OLA Enrollment No.: 1528/69373/11861 to & syotsne Katun Bis W/O Wm AE jane janet Sane ‘ane 1g. Saranrampur Oakshin Dinapur © wrest Senge! 729140 2 A am NOTESSITASOPH SWAT aT aA / Your Aadhaar No. 2946 2463 0003 AT sreng, A Wea Far ae, AR SEAT yotena Khatun Bi Husband = Mujam Al (DOB: 04ros/1091 Female