Request For New PAN Card Or/And Changes Or Correction in

PAN Data
Only 'Individuals' Only 'Individuals'
to affix recent to affix recent
colour colour
photograph photograph
(3.5 cm x 2.5 cm) (3.5 cm x 2.5 cm)
Permanent Account Number (PAN)
E D R P K 9 0 7 5 H
Please read Instructions 'h' & 'i' for selecting boxes on left margin of this form.
Signature of applicant across
this photo

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 Signature of applicant (inside the box)
Last Name / Surname K O T H A
First Name S U J A T H A
Middle Name
Name you would like it printed on the PAN card
S U J A T H A K O T H A

2 Details of Parents (Applicable only for Individual Applicants)

Father's Name (Mandatory : Even married women should fill in father's name only)
Last Name / Surname S A M M E T A
First Name V E E R A
Middle Name S W A M Y
Mother's Name (Optional)
Last Name / Surname S A M M E T A
First Name S U D H A R S H A N A D E V I
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
3 Date of Birth 2 3 0 5 1 9 7 6 4 Gender Male Female
5 Photo Mismatch 6 Signature Mismatch
7 Address for Communication Residence Office (Please tick as applicable)
Name of office
Flat/Door/Block No. P L O T N O 7 9 6
Name of Premises/Building/Village H S N R R E S I D E N C Y
Road/Street/Lane/Post Office V E N K A T A R A M A N A C O L O N Y
Area/Locality/Taluka/Sub-Division K P H B P H A S E 9
Town/City/District H Y D E R A B A D
State/Union Territory Pincode/Zipcode Country Name
TELANGANA 5 0 0 0 8 5 INDIA
8 If you desire to update your other address also, give required details in additional sheet
9 Telephone Number & Email ID details
Country Code Telephone/Mobile Number Email ID
9 1 6 3 0 0 5 3 7 3 9 3 KARTHIK.KOTHA777@GMAIL.COM
10 AADHAAR number (if allotted) 8 2 9 1 4 1 7 0 0 0 0 2
Name as per AADHAAR letter/card
K O T H A S U J A T H A

11 Mention other Permanent Account Numbers (PANs) inadvertently allotted to you

PAN 1 PAN 2 PAN 3
12 Verification
I/We SUJATHA KOTHA , the applicant, in the capacity of HERSELF
do hereby declare that what is stated above is true to the best of my/our information and belief.
I/We enclosed 3 (number of documents) in support of proposed changes/corrections.
Place HYDERABAD
Date 2 4 0 4 2 0 2 1

Signature of applicant (inside the box)

A3725571