Form 49A Application for Allotment of Permanent Account Number

[In the case of Indian Citizens/Indian Companies/Entities incorporated in India/

Unincorporated entities formed in India]
Under section 139A of the Income Tax Act, 1961

Date: 30/12/2018
Print

AADHAAR matched using Demographic details - will be linked with your PAN.

Payment Status: Success

Your Payment of Rs.107.00/- for one PAN Application has been accepted subject to realization
and final settlement confirmation from your Banker.
Please quote Reference No. PHDF7051041479 for any future correspondence.

Application/Coupon number : U-N003259762

PAPER APPLICATION (physical submission by

Application Mode
applicant)
PAN Card Mode Both physical PAN Card and e-PAN

Assessing Officer(AO Code)

Area Code AO Type Range Code AO No
APR W 80 1

1. Full Name (Full expanded name: initials are not permitted):

Last Name / Surname :-
Title:- SMT First Name:- MOHAMMED Middle Name:-
GOUSUNISSA BEGUM
2. Abbreviation of the above name, as you would like it, to be printed on the PAN card:- MOHAMMED GOUSUNISSA
BEGUM
3. Have you been known by any other name? N
Last Name / Surname :- First Name:- Middle Name:-
4. Gender:- FEMALE
5.Date of Birth / Incorporation/Agreement/Partnership or Trust Deed/Formation of Body
14/05/1967
of Individuals/Association of Persons:-

6. Details of Parents (applicable only for Individual applicants):-

Whether mother is a single parent and you wish to apply
No
for PAN by furnishing the name of your mother only?
Last Name / Surname :-
Father's Name : First Name:- MOHAMMAD Middle Name:-
RASHID BASHA
Last Name / Surname :-
Mother's Name : First Name:- MOHAMMAD Middle Name:-
RAHAMATUNISSA BEGUM
The name of either father or mother which you may like to
FATHER'S NAME
be printed on PAN card :

7. Address:-
Residential Address:-
Flat/Door/Block No.:- 24/7/181 MAGUNTA LAYOUT
Name of
Premises/Building/Village:-
Road/Street/Lane/Post
Office:-
Area/Locality/Taluka/Sub-
Division:-
State/Union
Town/City/District:- PIN Code:-
Territory:- ANDHRA Country:- INDIA Zip:-
NELLORE 524003
PRADESH
Official Address:-
Office Name:-
Flat/Door/Block No.:-
Name of
Premises/Building/Village:-
Road/Street/Lane/Post
Office:-
Area/Locality/Taluka/Sub-
Division:-
State/Union
Town/City/District:- PIN Code:- Country:- Country:-
Territory:-
8. Address for
RESIDENCE
Communication:-

9. Telephone Number & Email ID Details :-

Country Area/STD Telephone/Mobile Email
91 0861 8074799656 gousunisa@gmail.com
Code:- Code:- Number:- Address:-
10. Status of the Applicant:- Individual
11. Registration Number(for
Company,firms,LLP's etc):-
12. Please Mention your AADHAAR
322811775467
Number(if allotted) :-
If AADHAAR number is not allotted,
please mention the enrolment ID of
Aadhaar application form :-
Name as per AADHAAR letter/card or
as per the Enrolment ID of Aadhaar MOHAMMED GOUSUNISSA BEGUM
application form :-

13.Source of Income

SALARIED Capital Gains

Income from Business/Profession Income from Other sources

Income from House property No income

14. Full Name, address of the Representative Assessee, who is assessable under the Income Tax Act in respect of the
person, whose particulars have been given in colmns 1 to 13.
Title:- SHRI Last Name:- IMTHIAZ Middle Name:- First Name:- MOHAMMED
Flat/Door/Block No.:- 24/7/181 MAGUNTA LAYOUT
Name of
Premises/Building/Village:-
Road/Street/Lane/Post
Office:-
Area/Locality/Taluka/Sub-
Division:-
Town/City/District:-
State/Union Territory:-ANDHRA PRADESH PIN Code:-524003
NELLORE

15. I/We have enclosed AADHAAR Card issued by UIDAI (In Copy) as Proof of Identity , AADHAAR Card issued by
UIDAI (In Copy) as Proof of Address and AADHAAR Card issued by UIDAI (In Copy) as Proof of DOB.
16. I/We MOHAMMED GOUSUNISSA BEGUM ,the applicant,in the capacity of HIMSELF/HERSELF do hereby declare that
what is stated above is true to the best of my/our information and belief.

NELLORE

Signature/Left thumb impression of the

Place Date
applicant