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

Acknowledgement Number: N- 881132133852795

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

Assessing officer (AO code)

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

across this photo
PTN W 27 96

Sir, I/We hereby request that a permanent account number be allotted to me/us. Signature / Left Thumb Impression of
I/We give below necessary particulars: Applicant (inside the box)
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 SAH
First Name AMOL
Middle Name
2. Abbreviations of the above name, as you would like it, to be printed on the PAN card
AMOL SAH
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
08/09/2007
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 SAH
First Name GANESH
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 DEVI
First Name ANITA
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. 10

Name of Premises / Building / Village KARAHUAN GOT

Road / Street / Lane/Post Office AWARI

Area / Locality / Taluka/ Sub- MADHWAPUR
Town / City / District MADHUBANI
State / Union Territory Pincode / Zip code Country Name
BIHAR 847308 INDIA
Office Address
Name of office AWARI

Flat / Room / Door / Block No. 10

Name of Premises / Building / Village KARAHUAN GOT
Road / Street / Lane/Post Office AWARI
Area / Locality / Taluka/ Sub- Division MADHWAPUR
 Town / City / District MADHUBANI

State / Union Territory Pincode / Zip code Country Name

BIHAR 847308 INDIA

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 7070670182

Email ID AMOLF511@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 of Aadhaar application form as per section 139AA
Please mention your AADHAAR number (if allotted) XXXXXXXX6112

Name as per AADHAAR letter/card of Aadhaar application

AMOL SAH
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 AMOL SAH 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 AWARI
DD MM YYYY
Date 08/09/2025 Signature / Left Thumb Impression of