Request For New PAN Card Or/ And Changes Or Correction in PAN Data
Permanent Account Number (PAN)
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Please read Inslru ction sh& i' fo r selecting boxes on left margin of this fo rm_
1 Flll Name {R ll erpan& narie to be mertion€d as appearing in proof o, identity/address
doc ments: initials arenot perhitted)
Please serecf lrtle, as applicable Shri Smt Kumari M/s
Lasl Name / Surname
First Namo
l\y'iddle Name
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Father's Name (Mandato Even maried women should lill in father's name
Last Name / Surname
First Name
l,4iddle Name
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Mother's Name (opti
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Last Name / Sumame
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First Name
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Select the name of elthertather or mother which you may like to be printed on pAN card (Select one ohly)
(ln case nooption is providedthen PAN cs.d will be issued with tather,s name) Mother's l{ame (Pleasetick as applicable)
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Da Month Year
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Name of Offce (o be flred ont in @se ot offce add@)
FlauRoom/ Door / Block No.
Name of Premises/ BuildingMllage
Road/Streeu Lane/Post Oftice
Area / Locality / Taiuka / Sub- Division
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Town/City/District
State / Union Tenito Pincode / code Name
Counlry code Area/STD Code Telephone / Mobile number
Email lD
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Name as AADHAAR letter/card
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PAN I PAN 2 I I TTI l PAN 3 I ttt PAN ,l I I
lM/e ,lhe applicant, in lhe capacity of do
declare that what is stated above is true to the best of my/our infomation and belief.
l/we have enclosed (number of documehls) in support of proposed changes I correctionr.
Place
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Date
icant nside thebox
Notq As per provisions o{ Section 2728 ol the lncome Tax Act., 1961, a penalty ol < 1O,0OO can be levied on possession ol more than one pAN.
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PAN Application Acknowledgment Receipt (For
Changes Or Correction in PAN Data)
( Physical Application )
Received Rs. 107.00/- (incl of taxes) from: SHRI SURESH SHRAVANJI KANTHALE
pplication No./Coupon No.: u-Q022369946
PAN Number: xxxxxxTS5H
Name as to be printed on PAN card: SURESH SHRAVANJI
KANTHALE
ender MALE
Date of Birth/l ncorporation 01/05/1960
SURESH SHRAVANJI
l|ililUil1 1ilililil
Narhe-: .r.. ,;,11r,,
QQ22369946
KANTALE
dhaar Number/ElD Number xxxx-xxxx-0364 luerrroNeo,
MATCHEDT
SURESH SHRAVANJI KANTHALE
pplicant's Contact details:
RESIDENCE State MAHARASHTRA
AADHAAR Card issued by UIDAI {ln Copy)
Proof ofAddress: AADHAAR Card iss ued by UIDAI ( ln Copy)
uedr,byrrUlDAl ( copV)
PAN Proof Copy of PAN Card
141121202511:43:23 ,:
Mode of PAN Card: Both physical PAN and e-PAN Card
Pa ent Date ':il:.::i:,.1,,',5348114121970782/ PY0166539011
14t12t2025
MATCHED USING DEITOGRAPHIC DETAILS.
1312122300
PAN Service Center Name: 131212230016 (Sign/Stamp
Received for submission to UTIITS
know your status, you may visit our
p tn structi n fto m n come Tax Depa rlm ent, n a uthorize d ag ncy' s agent may It you for your identity and address verification as per the documents
b mitted by you with th PAN a pplicati n form. You a re req uested to ask authorization letter/lD card trom the agent before [Link] cooperation is
n this rd
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