Appiicato. Nu.

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|Payment Reference:PY0005841733
S8 Pavment Date:
06/10/2023 Rs.107.00/
M040CARRAACTOrKRATCLTCC
179757} User Name: MINDAOP-PAY179757128 jApyiaiu
Jth physical PAN and e-PAN Card
Application Mode : Physical App
Form No. 49A
Application for Allotment of Permanent Account Number
[In the case of Indian Citizens/
Indian Companies/ Entities
incorporated in India/
To aved U..vipiini,unni.i
stakes. piease fotkn
aSoDpatiyira
See Ruyley 114
istrcons and sKarnres befo flg up the form
Assessing officer (AO code)
Sidhonta Area code
AO type Range code AO No.
nature tLetrutres or
B N W 2
93
ir, 1We heroby
We give below
request that a Permanent AcCOunt Number
necessary particulars
be allottod to me/us
Sidhonte
Sgraturel et Thumb Inpression
Pleaso select title. as applicable
Last Name / Surname
Shn Smt Kumari M/s

First Name
BARA L
| S | I | DIHIAINIIL AI
Middle Name
Abbreviations of the above name, as you would like it, to be printed on the PAN card
BAK A|L
Have you ever been known by any other
If ves. please arve that other name
name? JYes No (please tick as applicable)
Please select title. as applicable Shri
Last Name /Surname
St. Kumari M/s
First Name
Middle Name

Date of
Temate
Birth/lncorporation/Agreement/Partnership
Formation of Body of individuals or association
Persons of
or Trust Deed! Day

|19|
Month

o3
Year
Datnile of Parente f
annlirnhie onhy for indiviun
anneante)
Whether mother is a single parent and you wish to apply
|1998
for PAN by
mother's name in the appropriate space provided fumishing
If yes, please fill in
below.
the name of your mother only? Yes
No(please tick as applicable)|
Fathers's Name (Mandatory except where mother is a single parent and PAN is applied by
B4RA!T furnishing the name of mother only)
First Name
Middle Nane
|LOKIA NATH
Mothers's Name (optional eKcept whare mother is a single
parent and PAN is applied by furnishing the
Last Name / Sumame name of mother only)
First Name
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 provided then PAN card will be issued with father's
is
PAN by furnishing name of the mother only) name except where mother is a single parent and you wish to apply for
Addross Father's name Mother's Name Ptease tick as applicahle)
Residence Address
Flat / R0om / Door / Block No. BRAH MANSAHI
Name of Premises / Buildingi Village BADANA|UKONA
JBADAI NAUlKINA
Area / Locality / Taluka/ Sub- Division
Town /City / District
State /Union Territory KENIDRAPARIA
Pincode !Zip code Country Name
ODI SHA |754 22 5 |N D| A
Office Address
Name of office
riai, ROUN UOUr biuCK vO.
Narne of Premises ! Buiding i Vitlage
Road / Street / Lane/Post Office
 Date
ig
Place do[Annexure 15
aaa (Please enclosed
have
IWe
Documents
as
hereby State
proof Town Area Road Name Flat
AddressMIOgIe
Naine Name
First Last 14 3
SIDHANIA Representative
Full been IZ
refer / / / Income Naine 10
declare A, of Union City
Locality Streel / ofRoom / Name income
Source of HAALHAAR in
BADANAUKONA Premses
Name gven
Case Peae
selnt
tats Status
DDM Annexure address to submitted / Telephone
Addrese
as
t he TerritoryDistnct / / from Trusts
that / / Door Surname (Full n por of of
Lane/Post
Taluka/
instructions and Busnessthe AAUNAAN a appic
what BARAL / expanded Assessee numbo person, for
B Buiiding Biock column
&Annexure as CommsreN
Sub- ant
is AADHAAR nher
AADHAAR Proof Office No. s who
staled Division i 1-13. Profession / IeIte:carg not A
(as Village name (RA) Emit
of allotted, is Indrvduats
Bochy
undded
offamly
Hdu ati
above specified
C ldentity required
are : Ddet
tnitials or
to Card Card piease
is HANTA D
S as to
T
true be in (POI). Business/Profession
code por :te
are quote
ino mentxon
used Rule issuedissued
to Proof not
the wherever 114 cnromont Aadhaar
permitted)
the
best of by by of
enrolment
I.T . UDAI Address number/The
ofapplicable] IU Athonty
Loca vResdence
Compary
my/our Rules, as OT
Aaanaar
proof ID
1962) (POA) 44644
Signature information as of
Sidhawa proof of Enroimert
Aadhaar
appiicatIOn
B|ARA
for identity, and
list of Proof (For application
Left / and ofdate
AADHAAR ID
Code: foT JPartrershipFrm
Thurmb belief. mandatory of of of Artifictat
Persons
Aurirteal
Aadhaar
birth. Date Refer Oomce
form
HIMSEIFIHERSELF
Impression of instructions]
certified Birth application
Card
(DOB)
of documents issued
form (Please
Applicant Please
as DGovenment
by Income tick
to per Assocaton
Persons of
be UiDAI setect.v Imated
section as
(inside from
submitted appllcable)
Pincode Iatlty L
Other
the 139A
as
box) as sources Partnershp
appiicable
appiicablel
 aIaS
niaua
125005888 FSEnrolment
1358/26751/58448No.
61 Badanaana
754225
Odisha
9938979928 Brahmansahi
Po-Badanaukona
A-Braharsahi
Kendrapara
Rajnagar
04/06/2013
Lolcanath
BaratSO
Sdhana Baral To
6723
9396
2512UNSHI ME250058882FH
BARAL
90/MalLOKANATH g Sidhanta
e Father: Baral iontiication
2512
6723
9396 ora
ll0, DOB /

19/o31998 Your / Ahart

61
Aadhaar 31TETR
a06 of
lodia
No.:
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