‘orm No. 490 Application for Allotment of Permanent Account Number {in the case of Indian Citizens/indian Companies/Entities incorporated In Indial Unincorporated entities formed in nda) ‘Assessing officer (AO code) i ‘rea code ‘AO type | Range code ‘AO No, \ K\|A|R (iW 4) 2\-4) 9) 3 Lie hereby request that a permanent account number be ated to meus. liWe give below necessary particulars: 11 Full Name (Full expanded name to be mentioned as appearing in proot of identiyidate of sii oer lan so pt Pine oean lsclemare [leat [leat beet hw DOD CY, Last Name /Sumame S/A|R/AD|AM/M/A 7 Fist Name I | idole Name I T 2 Abbreviations ofthe above name, a8 you would lik i, (sla/R/a/DiA MMA I ay [ Have you ever been known by any ot! ¢r name yes please gv ha er nar Peace sect te [7 ]eeappicatie [] sh Last Name /Sumame + Fist Name tao Name EEE Peet Peet anaes ee cal has (“lees ee eee ee ae (ola) (of2) [ajslel7 SNmTGE emaiaee ee Cees: 7 por ate) Soh in mother's name in the appropriate space prov Je below. Father's Name (Mandatory except wh re mother {please tick as applicable) ‘Association of Persons Last Name /Sumame (BAD) Fst Name CHIT Misdlo Name L Mother's Name (optional except where mother Is bet + er oF mother which you may ie Io be printed on FAN card (Select one ony) (Please tics a8 applicable) 1S¢ no option is provided then PAN card wil be issued with ather's name except where mothe ‘by furnishing name of tho moder ony) Last Name / Sumame Fest Nome Middle Name lect the name of ether ‘thers name stoners rame 7 Aadress Residence Address Frat Room /Doot/ Block No. WIAIRID| [Nlo| [0/2 Name of Premises /Buikieg /Valage [IN| B Road Skeet /LanePost Offer GULADA ‘Awa Locality /Tauka Sub-Owsion [K|O| P|P [AL ‘Town / City / District KOP PAL | | State / Union Terry Pine 1p code Country Name KARNATAKA Isis 3i2l2iel_]‘Ofice Address Name of ofc Fat / Room | Docr / Block No, Name of Premises / Building Vilage Road / Street /LaneiPost Ofice ‘Area / Locality / Taluka Sub- Dison Town / Gay / Distt State / Union Tertory 18 Address for Communication 9 Telephone Number & Email ID details County code Area‘STD Code Telephone / Mobile number 9] 9 9/0|2/9|9/4/8/2 IL. [V/s appicatie Government indus undivided family [company Postnership Fam Association of Persons Body of neivisuais Loc Autnorty J>ricol Juridical Persons [/ ]Limited Liatty Partnership ‘1 Registration Number for company, firms, LPs ete) f 7 7 Beier TI 12 Incase of a person, whois required tc quote Aadhaar numb» or the Enrolment IO of Aadhaar application form as per section 138.AA Please mention your AADHAAR number taloted) [7| 4] 3 [2]2|9/5|1[9|9[1]7 IFAADHAAR numbers nat alts. pea: © mention te enoime {1D of Andhar application fr T T T I | Name as por AAOHAAR itor card av 28 par bw Ervoinant of Asdhaarappcaion frm SA R/A[D AlMiMlA i eres I 12. Souree of come ‘ease solct |v] 28 applicable DD samy ae [] capt Gains Income from Business / Profession _Gusiness/Profession crde_[ {For Code: Refer instructions} Income from Other sources Income from House property [7] Ne income 14 Representative Assosso0 (RA) Fur nam, acess of the Representative Astoss09, who i a8 sible undr the Income Tax Act in respect of the person, whose patcuars have been given in he column 13. Full Name (Full expanded name : inti Please select ite, (V/]as applicable Lest Nome /Sumname T Fest Nome cl | T Made Name pal ‘Adress Flat / Roam Door / Block No Name of Premises /Butdng/ Vilage Road / Steet LaneiPost Oftce ‘vwa! Locally! Taluka Sub- Dion Town / Gy /Distnet State / Union Tertory re not permitted) I ] 15 Documents submitted a6 Proof of identity (PON, Proof of Adress (POA) and Proof of Date of Birth (POB) Wie have enciosed [AADHAAR CARD 8 proofotidentiy. [MADHAAR CARD as proof of acess nd [AADHAAR CARD] as proto date of it. {Pease retro he insvuctone (as species Ru Ta of LT uc 7852) for ist of mandsory certs cocuments tobe submited as applcale] [Annexure Annexure @& Ane C aro be used whereve ape 46 \We[SARADAMMA________________], th applicant. in he capacity of [HERSELF 2 \dohereby deciare thai what ls Saied above is rue to the best of mylour information and bet oO o Pisce [KOPPAL ® Ob, OpMMYYY yY ———g 7 AA : pas onc robs sovetabe och ag ge. Mhbaiah, madeabalaien, ea Jaf choos ae INFORMATION — = Aadhaar is proof of identity, not of citizenship . am Eat = To establish identity, authenticate online . ep Koooal a 1 ecact deeendjos atnatobah add . |" Gda,8O, xieaed merle Soaedead Seria, eb, eqee* dost, / Your Aadhaar No.: | Sdaben eo Aatt amanhdoorted 7432 2951 9917 |* tem svat tovostine country '= Aadhaar willbe helpful in availing Government| eet - Semeaivend,S Hse | and Non-Government services in futuro . reese vst, ‘ed, oo DOB O1O1H067 — Big aire Serco ant ey, tr, Gas, aa, Soon so ‘opt arena Sas 7432 2951 9917 eed - Semoarend,d obs 7432 2954 = : Eee sen a