Acknowledgment for Request for New PAN Card or/and Changes or Correction in PAN Data

ACKNOWLEDGMENT NUMBER: 881010205013525

Category Permanent Account Number (PAN) Name Name to be printed on card Father's Name Date of Birth Address for Communication Individual AMUPP5698M Shri SANJAY BHAYYAJI PUNEWAR SANJAY PUNEWAR Shri BHAYYAJI PUNEWAR 28-07-1964 B-3/004 SWASTIK PARK AZADNAGAR G.B ROAD THANE - 400607 Maharashtra 022 - 25899833 san_pan55@yahoo.com Signature Mismatch PAN3: PAN4: Sex

Affix recent photograph (3.5cm x 2.5cm)

Other Address Telephone No. Email ID Photo Mismatch PAN1: PAN2:

Request for cancellation of PAN(s)

Payment Mode
Cheque: Number 141619 dated 16-08-2011 (in dd/mm/yyyy form) for 94.00 in favour of 'NSDL-PAN', drawn on 16/8/2011 Bank, deposited at HDFC Bank, VILLE PARLE (EAST) Branch at VILLE PARLE,MUMBAI Location (city/town) (Cheque to be deposited in any HDFC Bank branch in your area and not to be sent to NSDL). I/We, the applicant, do hereby declare that what is stated above is true to the best of my/our information and belief. The following documents are enclosed as: Proof of Identity: Copy of passport Proof of Address: Copy of electricity bill Proof of PAN: No document Proof of PAN to be cancelled: Any other document:

Signature/Left Thumb Impression of Applicant (inside the box without touching the sides & in BLACK INK ONLY) Date: 14 - 08 2011

Preview Application Form

Service Tax Registration No.: M-III/ST/BAS/2847

New Application

Instructions:
1. The above-mentioned 15-digit acknowledgment number is a unique reference number for your application for 'Request for New PAN Card or/and Changes or Correction in PAN Data'. Kindly quote this number for tracking the status of your application on www.tin-nsdl.com or any queries relating thereto. Save and print this acknowledgment. Application fee and mode of payment: Payment favouring 'NSDL-PAN' can be made as follows:

2. 3.

Sr. No. 1

Address for Communication Indian

Amount payable (

) 94

Mode of payment Credit card / Debit card / Net Banking / Demand Draft (DD) payable at Mumbai/Cheque to be deposited in any HDFC bank branch across the country (except Dahej). DD payable at Mumbai

Foreign

944

4.

Please mention name of applicant and acknowledgment number on the reverse of cheque/DD.

5.

6. 7. 8. 9. 10.

Individual Applicants affix your recent colour photograph, sign the acknowledgment (inside the box provided without touching the sides and in BLACK INK only) and enclose a Demand Draft (DD)/Cheque, if any, alongwith Proof of Identity and Proof of Address as specified in the application form. Superscribe the envelope with 'APPLICATION FOR Change request PAN - Acknowledgment Number' (e.g., 'APPLICATION FOR Change request PAN - 881010200000973'). Send the documents as specified in point no. 4 above to Income Tax PAN Services Unit, National Securities Depository Limited, 3rd floor, Sapphire Chambers,Near Baner Telephone Exchange, Baner Pune -411045 Tel: 020-2721 8080; Fax: 020-2721 8081. Your acknowledgment, DD if any, and proofs, should reach NSDL within 15 days from the date of online application. Application will be processed only on receipt of relevant proofs and realisation of payment. Applications without proof of PAN will be processed on a good effort basis - (as mentioned in guidelines).