INCOME-TAX RULES, 1962 Form No. 494 Application for Allotment of Permanent Account Number os [in the case of Indian CitizeneiIndian Companies/Entities incorporated in Indial Sin Inara Unincorporated entities formed In India] Inga eae See Rule 14 “aosaraan eae Temedmise seme fon he scorparg tances andesanea re ling p the rm ee ” ‘Assessing officer (AO code) ‘Area code AO type Range code AO No. Ton La Thame apreon scat is at Sr, wie hereby request that a permanent account number be alloted to motus, Uwe give below necessary particulars ‘Spaiae Lat Ta apesson 41 Full Name (Full expanded name to be mentioned as appearing in proof of Identityidate of birthaddress documents: Initials are not permitted) Please select ite, [V]es applicable Shi sme ume []Ms Last Name / Sumame Fst Name idole Name 2. Abbreviatione of the above name, as you would lke it, to be printed on the PAN card 3. Have you ever been known by any other name? Yes No (please tick as applicable) Ifves, please give hat other ame Prease select te [¥ ]as applicable sh sme ]umen [7 ]oas Last Name / Sumame First Name Middle Name 4. Gender (for incvidual applicants only) (please tick as applicable) Mate [Female “Transgender 5 Date of BirthiIncorporation/AgreementPartnership or Trust Deed! Formation of Body of individuals or Association of Persons Day Monts Year LU {6 Details of Porents (plicable only for Inebvicuel applicants) Whether matbers a single parent ane you wish o apply for PAN by furnishing the name of your mother only? Yes[_] a6] (ease tick as anatcable {tyes please fn motes nome ia he appropriate space prove belo. Father's Name (Mandatory except where mothers single parent and PAN is applied by furnishing tre name of mother ony) Last Nome/Surname First Name ‘te Name Mother's Name (optional except where mother Is a single parent and PAN Is applied by furnishing the name of mother only) Last NamerSumame Fis Name be Name Selec the name of ether fter or mater which you may ke be pied on PAN card (Select oe on) [_[Fattersname[[Moters ane (Pas ick as applcabe) (it case no option is proved then PAN card willbe issued with father’s name except where mother is @ single parent and you wish fo apply Tor PAN by faishing name ofthe mather ony) 7 Address Residence Address Flat / Room / Door / Block No Name of Premises! Buling/ Vilege Road / Seo! LanePost Office ‘ea | Locally Taluka! Sub-Dsision Town City / District, State / Union Terry Pincode /Zip code Country NameOffice Address Nome of ofa Fiat Room / Door / Block No Name of Premises! aking | Vilege Road / Street Lane/Post Office ‘ea | Locality Taluka! Sub-Dsision Town City District, te Linon Teri nod |Z Coultiy Namie @ Address for Communication office: (Please tick applicable) 8 Telephone Number & Email ID details Country code Avea/STD Code “Telephone / Mobile number Email ID 10 Status of applicant Please select status, {V] as applicable [_] Government Individual Hindu undivided family ‘Company Partnership Firm |] Association of Persons Trusts oy of nds Loca Aunty Ail undca Prone [7] uted Libity Pars ‘11 Registration Number (for company, firms, LLPs ete. 12, Incase of o person, who is required to quote Aadhaar number or the Please mention your AADHAAR number iF allotea | AADHAAR number isnot allotted, please mention the Enrolment 1D of ‘Name as per AADHAAR letter or card ar as per the Enrolment 1D of Aadhaar 413° Source of Income Salary Please solect,|V | as applicable Capital Gains Income trom Business / Profession _Business/Profession code [} income from House property ‘44 Representative Assesses (RA) Full name, address of the Representative Assessee, who Is assessib Deer given in he column 1-13 Full Name (Full expanded name : initials are not permitted) fe under (For Code: Reforinstructons) [__] income trom Other sources No income ‘the Income Tax Actin respect ofthe person, whose partoulars have Please seact ue [V ]as appteabia sh sm kuman [7 ]ws Last Name / Sumame First Name Midate Name Address. Flat / Room | Door / Block No, Name of Premises / Building / Vilage Road / Street / Lane Post Office ‘Area! Locality / Taluka Sub- Divison ‘Town / City District tte Linon Terr Pingo 15 Documents submited as roof of identity (PO), raat of Adress (POA) and Proof of dace of Birth (PCB) We have enclosed 2s proof ef dentiy, {as proof of address and 2s proof of date of bith (Paso refer to tho instuchons (as spociiod RU 1TH GFTT Rules, 1062) for ist of mandatory cetilod documents to be submited as appicable] 16 we| Place pom My yyy Date the applicant, in tne capacty of do heraby declare that what is stalad above i tue tothe bast of my/our infarmaton and belt ‘Soraire/ Leh Thum inpressan of ‘Appear (nie the box)