Tax lnvoice cum copy.

to be kept with application

ment receipt of pAN Appllcatl on (Fom
To( lnvol@ cum 4eA)
N - 859319700000031
Number
Cat6gory lNDIVIDUAL
il Dare- 10 Jut 2021

GSTIN ofAppticant NA
Applicant,s am6 poLttrtENt VesuoEvA
cltowonRt
Name on Cad POLINENI VASUDEVA CHOWDARI

Fathedg Name POLINENI TIRUPATAIAH

lrlolhe/s Name
Dste of Blrlh/ lncorpoEflon 12 Jrn 2004
Communicalion Address State ANDHRA PRADESH (37)
Tolephone, iloblle t{umbel 91-903Aa7 5224
E{nall tD PANCARD8999@Gt\,4AtL.COtvl
Proof of lden ty AADHAAR Card ssued by lhe Unique
tdentiflcalion Authority of lndla
Proof of Addresa AAD R Ca rd by th U iq thori ly
Proof of DOB AADHAAR Card issued by the unique
tdentificaflon Aulhorily of lndia
Oh behatf or NSOL e-Governance I ntrastructure
Lihiied (pAN,Cenrrc l,1anaged by NSOL]
PAN applicatioh fee T91.00
Branch lD:85931
Steel City Securilies Limited SGST 9% 10.00
RR ONLINE SEVA INDIRA COLONY CGST 9%
pRADESH
NEAR B ACK S|DE OF BC HOSTEL KANtGtRtANDHRA {0.00
523230
tGsT 18% {16.3 B

Total(Rounded Ofo
{107.00
GSTIN:27AAACN2082Nl 28
CINi U72900MH1995p1C095642 SAC | 998319
This is a computer genera ted recei pt
and does not require signature.
Online PAAL,4 1.2
 ti
To
Form No. 49A
Application forAllotment of Permanent Account Number
e case of lndian Citizens/lndian Companies/Enlities incorporated in lndia/
Unihcorporated ehtlties formed in lndial
See Rute 114
aloid mislake (sl. please iollowthe accompanyng jnstrucrions and eyamptes beiore til ng up lhe lorm
a
Assessing officer (AO code)

lt Area code AO type Range code AO No

Siqn / tett Thumb lmpr€ssion
A p d. N I 1 h
Sir, ?l/cr8'e&Ua0l"a'la>zc
lA/Ve hereby request thata permanent account number be allotted to me/us
ln^/e give below necessary particulars:
Signalure / Lefl Thumb lmpressron

1 Full Name (Full expanded name lo be mentionod as appearing in proof of identity/date of birth,faddress documents: initials are not permitted)

Please select titJe. as applicable Shri Smt. Kumari N,4/s

Last Name / Surname tr) c c 1-t a vt o 9r I

First Name ? o L t xl t: N, i
l\,4iddle Name

2 Abb.eviations of the above name, as you would Iike it, to be printed on the pAN card

II
_-]
q U D t: C i-r o u. I
-T-[ IT IfT-
3
9 ti L !
Have you ever been
N C: AJ- L fTl
k[own by any olher name? Yes
Tt tf
No
LTTr_ fTT
(please tick as applicable)
I

lf yes, please glve lhat other name

Please select title.

El las apptrcab e Shri Smt Kumari I\,4/s

Last Name / Surname

First Name
l\,4iddle Name

4
f] TransSenAer
Gender (fo. lndividual appticants onty) ale Female (please tick as appticabte)
5 Date of Birth/lncorporation/Agreement/Paftrership or Trust Deedl Formation of Body of individuals orAssociatioh of persons
Day Month year

6
tE 6 s)o
"l\
Details of Parehts (applicable onty for individual applicants)
Whether mother is a single parent and you wish to apply for pAN by furnishi ng the name ofyour motheronly?

Yes (please tick as applicable)

lf yes, please ill in mother's name in the appropriate space provide below
Father's Name (Mandatory except where mother is a single parent and PAN is applied by furnishing the name of mother onl
v)
Lasl Name / Surname T t A p A T l-l
First Name 0 o L t ,v G N t
[,4iddle Name
Molher's Name (optional except where mother is a single parent and pAN is applied by furnishin g the name of mother only)
Last Name / Surname
First Name

l\,4iddle Name
Select the name of either father or mother which yoi.r may like to be printed on PAN card (Select one only)
ather's name I\,4othels name
(Please tick as applicable)
(ln case no option is provided then PAN card wili be jssued with father's name except where mother is a single parent and you wish to
apply for pANl
by furnishing name of the mother only)'.
7 Address
Residence Address
Fiat / Room / Door / Block No. +
Name of Premises / Building / Village € M ,1 $. $4
Road / Street / Lane/Posl Offce € t! A R f,4
Area / Locality / Taluka/ Sub- D vision
.,\. 'frt.i IPt//. DistriDr '.' .. ir . ' M 4 L A I p o -t
State / Union Territory Pincode / Zip code Counlry Name
(/ ti atH L :l i .s AJU I it
 Office Address
Name of office

Flat/ Room / Door / Block No.

t l|]| t t l I, .TTT_rT_-]
rT-tl-l]
Name of Premises / Building /Village l|l
Road / Streel / Lane/Post Office

Area / Locality / Taluka/ Sub- Divlsion

IIII
Town/City/Distrlct
State / Union Territory Pincode / Zip code Country Name

d
g
t
^-d'*t!sk6n'
Telephone Number & Email lD details
16,1
.-,
1:, : '. .' Residence
T Offfce (Please lick as appllcable)

Country code Area/STD Code Telephone / N,4obile number

lc o 3 o 5 L 12- ll
Email lD
10 Status of applicant
Please seiect status, as applicable Government
lndividual Hindu undivided family Company Partnership Firm Association of Persons
Trusts Body of lndividuals LocalAuthority Artificial Juridical Persons Limited Liability Partnersh p
1'l Regisi.ation Number (for company, firms, LLPS etc.)

I f t fT
12 ln case o,
I
a person, who is aequired
fT-l=T-fT-[ l| l
lo quot€ Aadhaaa number or the Enrolment lD of Aadhaar a pplication fo.m as per seetion 139 AA
T] T T_T_TI
Please mentron your AADHAAR number (if allotted) 2 Li
b I oE T ?_ 5 a3
IfAADHAAR number is not allotted, please mention the enrolment ,D ofAadhaar a

fT-fT-t-t-TT-
Name as per AADHAAR letter or card or as per the Enrolment lD ofAadhaar a
m lication form

Lltl
tl
ication fo[m
I lvl"ls o
ffi
? O L G ( o IJ D u.
LfT_l-T_|-l
13 Source of lncome
|]t *tt-tt-Fl-l l
I

Prease serecf,
++t as applicable
Salary Capital Gains

F
lncome from Business /
lncome from House property
Profession Business/Profession code II [For Code: Refer instructions]
t lncome from Other sources
No income
14 Representative Assessee (RA)
FLrll name, address of the Representative Assessee, who is assessible under the lncome Tax Acl in respect of the person, whose particulars have
. been given in the column 1-13.
Full Name (Full expanded name : inilials are not permitted)

ffi
Please select title as applicable hri Smt Kumari Nl/s

t a l) ?
[r-r-
Last Name / Surnarne I T 1
First Name
[,4iddle Name -I
0 a I t N N T

m
I

Address
Flat / Room / Door / Block No. j j l
fTrrT-fT-t- I lttttt
L1l
tl m
Narne of Premises / Building / Village
L: M A ( ,! M
Road / Slreet / Lane/Post Offlce
Area / Locality / Taluka/ Sub- Division
Town/City/District
State / Union Territory
m
fv\
€ M

& (
A A

a t) O
i1

r ft-t- ffi
Pincode
L-,- pr.-(qq4."- tz 3 I
^-'^d
15 Documents submitled as Prool of lden ty (POl), Proo{ ofAddress (POA} and Proof of Date of Birth (POB)
l^y'/e have enclosed asproofofidentity, ffi
as proof of address and f as proof of date of birth
-f-r-*----Sr- -"-
[Please refer to the nstructons (as specified in Rule 114 of l.l Rules, 1962)forlistof mandatory certified documents to be submitted as applicable]
[Annexure A, Annexure B & Annexure C are to be used wherever appl]cablel
16 lANe Cta[,
, the applicant, in the capacity of
do hereby declare that what is stated above is true to the best of my/our information and belief.

Place: ka,!.y', i Frle ogla tlrrailaa

D Di,4 I\,4 Y YY Y Signature / Left Thumb lmpression of
Date
ro)Fl7T,Tqt[] Applicant (lnside the box)

Nl^ro Acn4.nr^wici^.c^fC6.ti^nr7rR^flhpln.^maT:vA.t lqAi .^pnaliw^lalnnnn..hhprovipd^nn^cca.c^nofm^rarh.n^neEIANI

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#odi s*jBr .f,-ds

Polinehi Vasudeva Chowdarl
-SC-:.J'SJ': sro AdJ5:lobr. l 1'. Addross: SIO Tirupataieh. 337,
5rl6{ra $06o0, i*rtdo. Manipudi Mandalam, Vema
8{;5 t *, \coriear ot Ei h : 2004 Varam, Vemavaram, Prskssam.
3X,jS6o,
li:y'xo. sola l:69- Andhra Pradesh, 5231 11
5231ll

34257361 8872

sG.5 - i-S,r5:g0 Xr"$3-

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