Application NumberAQBO6703 Sir, MWe hereby request that a permanant Acco Ie give below necessary particulars: Please seloc ite,| 7] as applicable lv] Last Name / Sumame 11 Full Name (Full expanded name to be mentioned at unt Number be allotted to mei. sm Kumari a 49886 7S > > 2 _jPayment Oot (08/01/2024 Rs.107.00/- Application Source: [EWALLET - A- CSC E GOVERNANCE SERVICES INDIA LIMITED |Application Date:|08/01/2024 } User Id:[647275620019 JUser Name: [_ IPAN CARD MODE : Both physical PAN and e-PAN Card [Application Mode : Physical Application eek Form No. 494 af ‘See Rule 114 oe inh un pis ue nS a ccs Sdn = Assessing officer (AO code) egies ere reer A P R Ww 8 5 9 2 dDSv rng in proof of identty/address documan hus wunthy ‘are not permitted) ATRILIA) 0 First Name NIATRIA Migte Name zZloJo[x Y = | I | Abbreviations of the above name, as y¢ be printed on S|A]T YAINIA|RIA|YTA UJRIT|H]Y. K LETT Try} Have you ever been known by any other tyes, please gve that other name name? yes [V] No Please sotect ite, [y”] as appicable Last Name Sumame First Name ‘Middle Name tick as applicable) ‘Gender (for individual applicants only) Date of Birthiincorporation/A, Dotails of Parents (applicable only for in Whether mother's a single parent and you tyes, lease filin mother's name in the apy pt Fathers's Name (Mandatory except where m \groomentP. Formation of Body of individuals or association of Per wish to apply for ropriate space provided below. ther Isa single parent an Day artnership or: 2 0 vidual applica ‘of your mothe lod by furis Last Name / Sumame First Name Mile Name ‘Mothers's Name (optional except where mother i 16 of mothor only) Last Namo / Sumame First Name Middle Name D Is] K N iv [al U[MIA|R Select the name of either father or mother which ye (ln case no option is provided then PAN card will be PAN by fumishing name of the mother only) ‘Address jou may lke fo bo printed on PAN ard incr 3¢ issued with father's name except wher [Jere v lame re mother is ene ot) 1 arcties ‘single parent and you wish to apply for Residence Address Flat / Room / Deor / Block No. Name of Premises / Building! Vilage Road / Steet / Lane!Post Ofco ‘Area / Locality /Talukal Sub- Division Town I City /Distict KISJo 5) s 0 E 1 f >[>[<|>| =|=[m) Stale / Union Territory eS i>[>p> ANDHRA PRAD ESH Office Address Name of ofice Flat / Room / Door / Block No Name of Premises / Building / Vilage Road / Street Lane/Pos! Office- | T ] Sea oc oka Seb- Orn + | TH I f + Ton CyB I TTI J 8 Address for Communication v7] orice 8 Telephone Nenber& Emal 10 detais Comtyeaie Nea STO Cade Totephone Mabe number eh I esp elenth tevaito [durvesula Kameswarao@gmalcom 10 stats of sppteant, Pease seuct sus, [Y]as appcane Govereeet vera — [ravnaaietanay [Jesnpeny pavesnprim —— [_]moctnono Penne ts [Joey of ius Loca Aunony Jt sre Persons [7] LntodLobiy Pare 1 Registration Number for company. fms LLP te) 12 nase ofa person whe is required to quote AadhaarnumberTheEnrolmentiO of Aadhaar application form ax par ection 1304A Pease menton you AAOHAAR muro ot totes) (7]1] 4] 9] [6] 2] 3] 9] [4[o[a] 2 EET I covenant tear GEL (D]]vfArKy areal [Salt] y] ALN ALIA YIAINIAL uM) (ulgittHly] Tf iste Ee) TH LITT Tit LLTTT1 LL] ase sle, [7] os appeabie Salary 1 income tram House property to eome Capital Gains Income tom Busness/ Profession BusinesxProfession code 1ForCode: Reter nsvuctons) [_] Income tom Otser sources ‘Te Represontative Assossoe (RA) Ful ana aren oft Repeseriave Aces, who aseasie under nce Tax Ath ese oro, wise parr have given ne earn 1-13, | Flame (Fl expanded name ills re not perma) Proase eetoct le, [7]=s applicable [7] sn Js. }komari [Jone Last ame Summa PICIENALSEICIEIES Fat Nome xlalmle[s[wla[r]a daa Nome Bato ‘Across Fiat Roam oor Beck No IEP Name of Promises Buldng vitage [K]O]T|#[alel=lm]t] a aad Shoot LanePost Otic Rlalslalvlelelofel pecs toaty/Towast-Oveon [RL [ole fale[afo fol [st [o[lolelelalala lela le [a Town iy Ost vietstatelataletatritatel DDL Stata / Uno Teoy ANDARA PRA De 8 HlS]3]io[s[a[ JPncowm 45 Documents submited as Proof of entity PON, roof of Adérss (POA) and Proof ef Dato of Binh (008) tune naveencoses [ _AADHAAR Card issued by | as poo of wenty, MAOHAAR Card issued by UIDAT | 3s proot of aséess and [AADHAAR Card fesued by UIDAT ] as poota at of btn [Please oer to the instuctons (as speci i Rule 11 of IT Rules, 1962 for at of mandatory ceed documents tobe submited as Manexire A. Amen B & Arment C are tobe sid wherever applicable] 16 tw DURVASUCA KAMESWARA RAO). wo apptcan. nthe conciy ot REPRESENTATIVE ASSESSEE | horoby doce fat whats sited above is tre othe best of myour infomation and bei pace: [KOTHAPENTA ppt) D-Sn-monthy oo owe: [os MM yy op [zyo ‘Signature / Leh Thumb impression of Applicant (nado the box)