Since the application is digitally signed using eSign/eKYC, there is no need to forward physical documents

Acknowledgement Number: N- 990039751560495

Form NO. 49A
Only ‘Individuals’ Application for Allotment of Permanent Account Number Only ‘Individuals’
to affix recent [In the case of Indian Citizens/lndian Companies/Entities incorporated in India/ to affix recent
photograph photograph
Unincorporated entities formed in India]
(3.5 cm x (3.5 cm x
Under section 139A of the Income Tax act, 1961
2.5 cm) 2.5 cm)
To avoid mistake (s), please follow the accompanying instructions and examples before filling up

Assessing officer (AO code)

Sign/ Left Thumb impression AREA CODE AO TYPE Range Code AO NO

LKN W 23 94
Signature / Left Thumb Impression of
Sir, I/We hereby request that a permanent account number be allotted to me/us. Applicant (inside the box)
I/We give below necessary particulars:
1. Full Name (Full expanded name to be mentioned as appearing in proof of identity/address documents: initials are not permitted)
Please select title, as applicable Shri Smt Kumari M/S
Last Name/Surname SHIVSHANKAR
First Name

Middle Name
2. Abbreviations of the above name, as you would like it, to be printed on the PAN card
SHIVSHANKAR
3. Have you ever been known by other name?
If yes, please give that other name Yes No
Please select title, as applicable Shri Smt. Kumari M/S
Last Name/Surname
First Name
Middle Name
4. Gender(for individual applicants only) Male Female Transgender
5. Date of Birth/Incorporation/Agreement/Partnership or Trust Deed/ Formation of Body of individuals or association of Persons
Day Month Year
28/11/2003
6. Details of Parents (applicable only for individual applicants)
Whether mother is a single parent and you wish to apply for PAN by furnishing the name of your mother only? Yes No
(please tick as applicable)
If yes,please fill in mother's name in the appropriate space provided 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/Surname HEERALAL
First Name
Middle Name
Mother's Name (Optional except where mother is a single parent and PAN is applied by furnishing the name of mother only)
Last Name/Surname
First Name
Middle Name
Select the name of either father or mother which you may like to be printed on PAN card (select one only)
(In case no option is provided then PAN card will be issued with father’s name)
Father's Name Mother's Name (Please tick as applicable)
(In case no option is provided then PAN card will be issued with father's name except where mother is a single parent and you wish to apply
for PAN by furnishing name of mother only)
7. Address
Residence Address
Flat / Room / Door / Block No. Lalganj (mirzapur) Gram

Name of Premises / Building / Village Post- Matwar Halliya

Road / Street / Lane/Post Office Lalganj

Area / Locality / Taluka/ Sub-
Town / City / District Mirzapur
State / Union Territory Pincode / Zip code Country Name
UTTAR PRADESH 231211 INDIA
Office Address

Name of office
Flat / Room / Door / Block No.

Name of Premises / Building / Village

Road / Street / Lane/Post Office

Area / Locality / Taluka/ Sub- Division
 Town / City / District

State / Union Territory Pincode / Zip code Country Name

8. Address for Communication Residence Office Please tick as applicable

9. Telephone Number & Email ID details

Country code Area/STD Code Telephone / Mobile number

91 7202003867

Email ID RAMMURAT166@GMAIL.COM
10. Status of applicant
Please select status, as applicable Government

Individual Hindu undivided family Company Partnership Firm Association of Persons

Trusts Body of Individuals Local Authority Artificial Juridical Persons Limited Liability Partnership
11. Registration Number (for company, firms, LLPs etc.)

12. In case of a person, who is required to quote Aadhaar number/ the Enrolment ID of Aadhaar application form as per section 139AA
Please mention your AADHAAR number (if allotted) XXXXXXXX7279
If AADHAAR number is not allotted, please mention the enrolment ID of Aadhaar application
Name as per AADHAAR letter/card or as per the Enrolment ID of Aadhaar application
SHIVSHANKAR
13. Source of Income
Salary Capital Gains
Business/Profession [For Code: Refer instructions]
Income from Business / Income from Other sources

Income from House property No income

14. Representative Assessee (RA)
Full name, address of the Representative Assessee, who is assessible under the Income Tax Act in respect of the person, whose
particulars have been given in the column 1-13.
Full Name (Full expanded name : initials are not permitted)
Please select title as applicable Shri Smt Kumari M/s

Last Name/Surname
First Name

Middle Name
Address
Flat / Room / Door / Block No.
Name of Premises / Building /

Road / Street / Lane/Post Office

Area / Locality / Taluka/ Sub- Division

Town / City / District
State / Union Territory Pincode Country Name

15. Documents submitted as Proof of Identity (POI), Proof of Address (POA) and Proof of Date of Birth (DOB)
I/We have enclosed AADHAAR Card issued by the Unique Identification Authority of India as proof of identity

AADHAAR Card issued by the Unique Identification Authority of India as proof of address and

AADHAAR Card issued by the Unique Identification Authority of India as proof of date of birth.

[Please refer to the instructions (as specified in Rule 114 of I.T. Rules, 1962) for list of mandatory certified documents to be submitted as
applicable
[Annexure A, Annexure B & Annexure C are to be used wherever applicable]
16 I/We SHIVSHANKAR the applicant, in the capacity of Himself/Herself
do hereby declare that what is stated above is true to the best of my/our information and belief.

Place MIRZAPUR Signature / Left Thumb Impression of

Applicant (inside the box)
DD MM YYYY
Date 17/07/2024