ACKNOWLEDGMENT FOR REQUEST FOR NEW PAN CARD

ACKNOWLEDGMENT NUMBER: 881010105847060

Citizen of India Y
Category Individual
Name Kumari Renuka Rengasamy
Name to be printed on card Renuka Rengasamy Affix recent
Father's Name Shri Rengasamy Vedhaiya photograph
Date of Birth 25-06-1988 (3.5cm x 2.5cm)
Residential Address 228-C
Fathima Nagar
Nanjikkottai Road
Thanjavur - 613001
Tamil Nadu

Office Address
-

Address for Communication Residential

Telephone No 91 - 9751793878
Email Id premsam.25@gmail.com

Payment Mode

Demand Draft: Number 185413003605 dated 21-11-2009 (in dd/mm/yyyy form) for Rs.94.00 in favour of 'NSDL-
PAN', drawn on Canara , payable at Mumbai.

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 voter's identity card
Proof of Identity of representative assessee:
Proof of Address of representative assessee:
Any other document:
Signature/Left Thumb Impression of Applicant
(inside the box without touching the sides & in BLACK
INK ONLY)

Date: 21 - 11 - 2009

Preview Application Form New Application

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

Instructions:

1. The acknowledgement number above is your unique reference number for PAN application. Kindly quote this number for

tracking the status of your PAN application on http://tin-nsdl.com or any queries relating thereto.

2. Save and print this acknowledgment.

3. Application fee and mode of payment: Payment favouring 'NSDL-PAN' can be made as follows:
 Sr. Address for Amount
Mode of payment
No. Communication payable (Rs.)

1 Indian 94 Credit card/ Demand Draft (DD) payable at Mumbai/Cheque to be deposited

in any HDFC bank branch across the country (except Dahej).

2 Foreign 744 DD payable at Mumbai

4. Please mention name of applicant and acknowledgment number on the reverse of cheque/DD.
5. Individual applicants affix your recent colour photograph (3.5 cm x 2.5 cm), sign the acknowledgment (inside the box
provided without touching the sides and in BLACK INK only) and enclose a DD, if any, alongwith Proof of Identity & Proof of
Address as specified in the application form.
6. Superscribe the envelope with 'APPLICATION FOR PAN - Acknowledgment Number' (e.g. 'APPLICATION FOR PAN -
881010100000973').
7. 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: 020-27218080; Fax:
020-27218081.
8. Your acknowledgment, Demand Draft if any, and proofs, should reach NSDL within 15 days from the date of online
application.
9. Application will be processed only on receipt of relevant proofs and realisation of payment.

10. PAN card will be despatched only to the communication address provided in your PAN application. Wherever the
Representative Assessee (RA) details ( item no.14 in Form 49A ) are mentioned in the application, PAN card will be
despatched to the RA's address.