Application Number: U-N006581344

Application Number Bar Code Payment Reference: ZHD51859164753 Inward Number Bar Code
Payment Date: 2024-03-27 21:01:32 Rs.106.90/-
Application Source: UTIITSL WEB-SITE Application Date: 27/03/2024
User Id: INTERNET USER User Name: INTERNET USER
PAN CARD MODE : Both physical PAN and e-PAN Card Application Mode : Digital Application (e-KYC)

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eKYC-Application

✔
M A N A
M I T H U N

M I T H U N M A N 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)
M A N A
J A C H I N D R 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) ✔

R A J N I L I G I R I N I L A G I R I R A J

N I L G I R I B A L E S H W A R

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 ✔

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bapimana8055@gmail.com

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M I T H U N M A N A

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

MITHUN MANA HIMSELF/HERSELF

NILAGIRI
eKYC-Application

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 Enrolment No.: XXXX/XXXXX/XXXXX
Download Date:27/03/2024

To
MITHUN MANA
RAJ NILIGIRI
VTC: Nilagiri
PO: Raj Nilgiri
District: Baleshwar
State: Odisha
PIN Code: 756040
Issue Date:09/12/2012

Signature Not Verified

Digitally signed by DS
UNIQUE IDENTIFICATION
AUTHORITY OF INDIA 04
Date: 2024.03.27 21:02:15
IST

4063 8254 6699

Download Date:27/03/2024

MITHUN MANA Address:

Issue Date:09/12/2012

ଜନ ତାରିଖ /DOB: 10-09-1990 RAJ NILIGIRI, Nilagiri, PO: Raj Nilgiri,

Dist: Baleshwar,
ପୁରଷ/ MALE Odisha, 756040

4063 8254 6699 4063 8254 6699

Signature Not
Verified
Signed by :MITHUN MANA
Date : 27/03/2024 21:07:26
Reason : eSign Service
Location : India