Since the application is digitally signed using eSign/eKYC, there is no need to forward physical documents
Acknowledgement Number: N- 881131143588710
49A
Only ‘Individuals’ Only ‘Individuals’
to affix recent to affix recent
photograph photograph
(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
Sign/ Left Thumb impression
BPL W 71 96
Sir, I/We hereby request that a permanent account number be allotted to me/us. Signature / Left Thumb Impression of
Please select title, as applicable Shri Smt Kumari M/S
Last Name/Surname
First Name
Middle Name
LALUA BAIGA
If yes, please give that other name
Please select title, as applicable
Last Name/Surname
First Name
Middle Name
(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 BAIGA
First Name TOBBA
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)
Flat / Room / Door / Block No.
Name of Premises / Building / Village GRAAM-HARDI
Road / Street / Lane/Post Office NAWALPUR
Area / Locality / Taluka/ Sub- SHAHDOL;
Town / City / District SHAHDOL
State / Union Territory Pincode / Zip code Country Name
MADHYA PRADESH 484001 INDIA
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 8815664727
Email ID SOMKANT652@GMAIL.COM
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
Please mention your AADHAAR number (if allotted) XXXXXXXX7712
Name as per AADHAAR letter/card of Aadhaar application
LALUA BAIGA
Salary Business/Profession Capital Gains
[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 LALUA BAIGA 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 SHAHDOL
DD MM YYYY
Date 12/02/2025 Signature / Left Thumb Impression of
नामांकन म/ Enrolment No.: 2980/86253/42887
To
ललुआ बैगा
Lalua Baiga
S/O: Tobba Baiga,
ward no. 01,
madwa tola,
Graam- hardi,
VTC: Nawalpur,
PO: Nawalpur,
Sub District: Sohagpur,
District: Shahdol,
State: Madhya Pradesh ,
PIN Code: 484001,
Mobile: 8815664727
6770 1385 7712
VID
पता:
S/O: टो बा बैगा, वॉड न. 01, माड़वा टोला, ाम- हरद ,
Aadhaar no. issued: 05/10/2013
ललुआ बैगा
नवलपुर, नवलपुर, शहडोल,
Details as on: 12/02/2025
Lalua Baiga म य दे श - 484001
ज म त थ/DOB: 01/01/1984 Address:
पु ष/ MALE S/O: Tobba Baiga, ward no. 01, madwa tola, Graam-
hardi, Nawalpur , PO: Nawalpur, DIST: Shahdol,
Madhya Pradesh - 484001
VID
