Application Number: A082297910

Application Number Bar Code 66882313105518368138 / PY0114383420

Payment Reference: Inward Number Bar Code
Payment Date: 13/10/2023 Rs.107.00/-
Application Source: EWALLET - A19 - SPICE MONEY LIMITED Application Date: 13/10/2023

User Id: 780367 User Name: 780367

PAN CARD MODE : Both physical PAN and e-PAN Card Application Mode : Physical Application

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A R A T I P A T R A

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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.
Fathers’s Name (Mandatory except where mother is a single parent and PAN is applied by furnishing the name of mother only)
P A T R A
B I J O Y
K R I S H N A
Mothers’s Name (optional except where mother is a single parent and PAN is applied by furnishing the name of mother only)

(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 the mother only) ✔

A L I S A H A G A R H
A L I S A H A G A R H
D E B R A B A Z A R
P A S C H I M M E D I N I P U R
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P A T R A
M A N I K A

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A L I S H A G A R H
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P A S C H I M M E D I N I U P U R
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AADHAAR Card issued by AADHAAR Card issued by UIDAI

UIDAI (In Copy) (In Copy)
AADHAAR Card issued by UIDAI
(In Copy)

MANIKA PATRA REPRESENTATIVE ASSESSEE

DEBRA

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