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

ACKNOWLEDGEMENT NUMBER:

Affix recent
photograph
(3.5cm x 2.5cm)

Signature/ Left Thumb

Impression across this
photo

881030215265432

Category

Individual

Permanent
Account No.

AMJPM5824D

Name

Shri KAUSHAL B MEHTA

Affix recent
photograph
(3.5cm x 2.5cm)

Name to be
KAUSHAL B MEHTA
printed on card
Father's Name

Shri BHARAT R MEHTA

Date of Birth

08-10-1982

Address for
A 204,
Communication VIMALNATH APP.,
46, DIGVIJAY PLOT,
OPP. OSWAL SCHOOL,
JAMNAGAR - 361005
Gujarat
Other Address
Telephone No. 91 9662518547
Email ID

KAUSHAL_MEHTA08@YAHOO.CO.IN

AADHAAR No.
Photo Mismatch

Signature Mismatch

Request for cancellation of PAN(s)

PAN1:
PAN2:

Sex
PAN3:

PAN4:

Payment Mode

Net Banking: Your Payment of ` 105 against transaction number 401-1105240 has been successfully processed.

I/We, KAUSHAL B MEHTA 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 AADHAR Card issued by the Unique Identification Authority of India
Proof of Address: Copy of AADHAR Card issued by the Unique Identification Authority of India
Proof of Date of birth: Copy of Birth certificate issued by the Municipal Authority or any office authorised to issue Birth and Death Certificate by the Registrar of
Birth and Deaths or the Indian Consulate
Proof of PAN: Copy of PAN card
Proof of PAN to be cancelled:

Any other document:

Date: 25-10-2014

Service Tax Code (Registration Number): AAACN2082NST001

Service Tax Registration Category: BUSINESS AUXILIARY SERVICES
CIN U72900MH1995PLC095642

(PLEASE READ INSTRUCTIONS GIVEN ON NEXT PAGE)

Signature/ Left Thumb Impression of Applicant

(inside the box without touching the sides and in BLACK INK ONLY)

Instructions:
1 The above-mentioned 15-digit acknowledgement 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
https://tin-nsdl.com or any queries relating thereto.
2 Save and print this acknowledgement.
3 Application fee and mode of payment: Payment favouring 'NSDL-PAN' can be made as follows:
Sr. No.

Address for
Communication

Amount payable
( )

Mode of payment

Indian

105

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

Foreign

971

Credit card / Debit card / DD payable at Mumbai

Please mention name of applicant and acknowledgement number on the reverse of cheque/DD.
4 Individual applicants affix your recent colour photograph (3.5 cm x 2.5 cm), sign the acknowledgement (inside the box provided
without touching the sides and in BLACK INK only) and enclose a Demand Draft (DD), if any, alongwith Proof of Identity, Proof of
Address and (Proof of Date of Birth - Indian citizens only) as specified in the application form.
5 Superscribe the envelope with 'APPLICATION FOR PAN - Acknowledgement Number' (e.g. 'APPLICATION FOR PAN 881010100000973').
6 Send the documents as specified in point no. 4 above to Income Tax PAN Services Unit, NSDL e-Governance Infrastructure
Limited, 5th floor, Mantri Sterling, Plot No. 341, Survey No. 997/8, Model Colony, Near Deep Bungalow Chowk, Pune -411016
Tel: 020-27218080; Fax: 020-27218081.
7 Your acknowledgement, Demand Draft if any, and proofs, should reach NSDL within 15 days from the date of online application.
8 Application will be processed only on receipt of relevant proofs and realisation of payment.
9 Applications without proof of PAN will be processed on a good effort basis - (as mentioned in guidelines).