Documentation & Statutory Forms-One Person Company Registration

The Companies Act, 2013 has been notified and with effect from 1st April 2014 the procedure and forms for
registration of One person company is introduced. Two set of self- attested documents as indicated in the
table below is required to register a one person company.
Document of Director *
Colour Photograph
Pan card self-attested
ID Proof: any of (voter id card / Passport /
Driving License / Aadhar Card)
Residence Proof : any of (Bank statement,
electricity bill, telephone bill, mobile bill)
Note:

Registered address proof #

NOC from owner

Conveyance/Sale deed or Lease deed or
Rent Agreement along with the rent receipts;
B) Any one of the below
Electricity
Gas

Bill

Bill Telephone Bill

Mobile Bill

Ensure that the scan documents are clear & visible

The address proof should be in the name of the applicant and shall have Pincode / Zip code in it.
Please ensure that the address proof is not older than 40 days (In case of Telephone bill, Bank
statement, Light bill & Mobile bill)
The Identity & Residence Proof must be attested by the Notary Public.
Before attestation and notarization of the documents, please email us the scanned copy of the
above mentioned proofs for checking and verification
The following forms need signature of Director / subscriber as explained

Sl.
No.
1.
2.
3.
4.
5.
5.
5.
6.
8.
9.
10.
11.
12.

Name of Form

Notary

*Order Form
*DIR-4 (affidavit for DIN allotment) (two set)
*DIN Single Name Affidavit (if required) two set
# INC-9 director/subscriber affidavit
# INC-3 Signature of Nominee
No NBFC Affidavit
#INC-10 Photo & Signature Specimen Form
#NOC from owner of premises
*Power of attorney in the name of professional
#Subscriber Sheet of MOA and AOA
*Digital Signature Form
Pan Card Application Form
TDS (TAN) Number Application Form

NO
Rs. 10 stamp paper + Notary
Rs. 10 Stamp Paper + Notary
Rs. 10 Stamp Paper + Notary
Plain Paper (pdf-prefillable)
Rs. 10 Stamp Paper + Notary
Plain Paper
Plain Paper
Rs. 100 Stamp Paper + Notary
Plain Paper
Plain Paper
Plain Paper
Plain Paper

Note: *: documents necessary to start the process

#: documents may be submitted after name approval of the company

Page | 1

Page
Number
2-5
6
7
8
9-11
12
13
14
15
16-17
18
19-20
21-23

ORDER FORM
Fill this form after reading instructions on the left side. The information should match with the documentary evidence which
promoters are submitting with the department. However if there is any discrepancy the same should be pointed out

Description
Select the kind of business
organization which you are
planning to incorporate.

No
A.

Particulars
Type of Organization
Public Limited Co

B.
The name of a public
limited company ends with
Limited , for a private
limited company it ends
with Private limited and
for an Limited Liability
Partnership it ends with
LLP,

Private Limited Co.

LLP

One Person Company

Proposed Name (Six names in order of preference)

1.____________________________________________________________
2.____________________________________________________________
3.____________________________________________________________
4.____________________________________________________________

An One person company

have to write (opc) after
private limited

5.____________________________________________________________
6.____________________________________________________________

Significance of the words

used in the name

Significance of Name

If proposed name is a
registered trade mark or a
trademark for which an
application is filed, there
will be more chance for
getting the name approved
for the Company /LLP

Trade Mark

Explain the nature of

business which you are
proposing to undertake in
the company or LLP.
Note: The activity must be
evident in the name of the
company

2. If No, Would you like to register the Trademark

Yes
No
Proposed Business Activity

Indicate The situation of

registered address in which
state.

State in Which Registered office shall be situated

Authorised capital is the

limit to which shares can be
issued. The govt fee
depends on this.

Capital of The Proposed Company / LLP

1. Whether the proposed name is a Registered Trademark

NO
Yes ______________________________

(Minimum Capital for Limited co- 5 Lakhs, PVT Ltd - 1 lakh, LLP 10,000)

Page | 2

Promoters & Directors Details :

If the proposed Director or
Designated Partner have
Director Identification
Number (DIN) then write DIN

To Obtain DIN, provide

following documents
1.
2.
3.

Two colour Photo

Self attested copy of
pan card
Self attested copy of
address proof

Apart from the documents

signature of the directors
shall be required on
following legal forms

1. DIR-4, which is an
declaration from the
director applying for
DIN with respect to
correctness of
information and
authenticity of of the
documents which he is
submitting

Proposed Director / Shareholder of OPC

Name : ________________________________________
PAN / DIN: _____________________________________
Email Id: _______________________________________
Mobile No: _____________________________________
Qualification ____________________________________
Occupation _____________________________________
Place of Birth ____________________________________
Period of residency at current address________________

Proposed Nominee
Name : ________________________________________

PAN / DIN: _____________________________________

NOTE:
The
director
and
shareholder can be same
person, there is no
restriction on relatives
becoming director or
shareholder in a company

Email Id: _______________________________________

Mobile No: _____________________________________
Qualification ____________________________________
Occupation _____________________________________
Place of Birth ____________________________________
Period of residency at current address________________
Note: If the number of director is more than 3 then kindly provide
information on separate sheet in the above format

Page | 3

Shareholding of the proposed company

Paid-up capital is the amount
of equity share which the
promoter
undertake
to
subscribe, this has to be
within the limit of authorized
capital and for a private
limited the minimum paid up
capital is Rs. 1,00,000/-

Paid up Capital ________________________________

And the same is divided in following manner

In case the shareholder is other than director then their information is also
required as per the format provided herein above (as in director)

The registered office shall be

the principal address for
official communication and
this need not be commercial
space.

Registered Office Address

..
..
..
..
State: .PIN Code ..

Address of police station

under whose jurisdiction the
registered office of the
company is situated

Address of Police Station

..
..
State: .PIN Code ..

KPS Fee Payment Details

with the order form, Detail
Package cost and working is
on the next page

Total Cost of Package: ..

Amount Received with the order Form :____________________
If paid in Cash then mention the receipt Number ____________
Cheque No. / Online payment Ref No. _____________________
Date of the payment ____________________________________

How to Order:
Complete this form and submit along with the required documents to the KPS Corporate
Consultants Private Limited, at their Head office or branch offices.

Order accepted without the complete documents and full payment as agreed shall not be
processed till the time all the pending document and the cheque is realized.

Page | 4

Final Order Financial Workings

S. No. Service Description
1.
Company Registration _______________________Pack

Amount (INR)

2.

PAN Number

3.

TAN Number

4.

Company KIT:

5.

Service Tax Registration

6.

Vat + CST Registration

7.

Trade Mark Registration

8.

IE Code (Import Export Code)

9.

Other Services:
.
.
.
.
.

TOTAL
We the promoters / applicants who have signed below declare that the information, documents, representations
made during the process of company/LLP registration is true, correct and nothing material has been concealed. We
further undertake to make the full payment of agreed fee within the agreed time frame.

Signature of Promoter 1

Signature of promoter 2

Date
Place:

Page | 5

Form DIR-4

Verification of applicant for application for DIN

(To be in the form of Affidavit)

[Pursuant to section 153 and rule 9(3) (a)(iv) of Companies (Appointment and
Qualification of Directors) Rules, 2014]
I, ..................., Son*/ Daughter*
of ..................................................................................................................., born on ...............,
resident of.........................................
.hereby
confirm and verify that the particulars given in the Form DIR-3 are true and also are in agreement with
the documents being attached to the Form DIR -3.
I hereby confirm and declare that
1. The photograph and documents being attached to the Form DIR -3 belong to me. I further
confirm that all required documents have been duly certified by the respective government
authority and are being attached to the Form DIR -3, and
2. I am not restrained, disqualified, removed of, for being appointed as director of a company
under the provisions of the Companies Act, 2013 including sections 164 and 169, and
3. I have not been declared as proclaimed offender by any Economic Offence Court or Judicial
Magistrate Court or High Court or any other Court, and
4. I have not been already allotted a Director Identification Number (DIN) under section 154 of the
Companies Act, 2013, and
5. I shall be liable under section 448 of the Act and under the relevant provisions of the Indian
Penal Code, 1860 and any other law as applicable, if any statement in this application is found to
be false or any material fact is found to have been omitted.
*Note: strike out whichever is not applicable.

Signature: _______________________________
(Name): _________________________________

Page | 6

Affidavit:
(If ID proof has single name for applicant)

I ____________________________________________________________ (Applicant Name as per id

proof), residing at __________________________________ ______ ________ __________ ______ ____
_____________________________________________________________________________________
_____________________________________________________________________(Address

as

per

address proof) do solemnly affirm and stated as under:

I am ___________________________________ and my name _________________________________,

appearing on the enclosed ID proof, is single name. My fathers name is _________________________
____________________________. For applying DIN application of mine, I am mentioning my fathers
name "_____________________" as my Last name, as this a mandatory requirement for applying DIN.
(Referred point no. 16 in FAQ at (www.mca.gov.in). Both names denote one and the same person.
I solemnly state that the contents of this affidavit are true to the best of my knowledge and belief and
that it conceals nothing and that no part of it is false.

Signature
Declarant / deponent

Page | 7

Form No. INC-9

Affidavit
[Pursuant to section 7(1)(c) of the Companies Act, 2013 and rule 15 of the
Companies (Incorporation) Rules, 2014]

Name of the proposed company: _____________________________________

I ., being the
subscriber to the memorandum / named as first director in the articles, of the
above named proposed company, hereby solemnly declare and affirm that:
formation or management of any company during the preceding five years; and
duty to any company under this Act or any previous company law during the
preceding five years; and
the documents filed with the Registrar for registration of the company
contain information that is correct and complete and true to the best of my
knowledge and belief.

Date:
Place:

Signature:

Page | 8

Affidavit

I (1) ________________________________________s/o __________________________________R/o_____________________________________________________________________________and the

promoter / director of the company under incorporation with name and style of M/s
_________________________________ via SRN no: _____________________ do hereby solemnly state
and declare that:

1. I am the first promoter / subscriber to the memorandum and articles of the company and also
the first directors of the company
2. That the company shall not accept deposits, unless compliance with the applicable provisions of
the companies Act, 2013, RBI Act, 1394 and SEBI Act, 1992 and rules/ directions / regulations
made thereunder are duly complied and filed with the concerned authorities.

Deponent

VERIFICATION

Verified today the ___day of__________ 2014 at_________ that the contents of aforesaid affidavit is
true and correct to the best of our knowledge and that nothing material has been concealed therefrom

Deponent

Page | 12

Form No. INC - 10

Form for verification of signature of subscribers

[Pursuant to rule 16 (1) (q) of Companies (Incorporation) Rules, 2014]

Size 4*4
(passport
size)

* to be attested by
Banker/Notary
1. Names, fathers name and Address of subscribers/first directors:
Name
Fathers Name
Address

2. Specimen signatures:

Attestation
(Signature of witness)
Note:
1. in point no. 1 above, strike off whichever is not applicable.
2. Person who is attesting should indicate his/her name, address and ID number.

Page | 13

To :
The Registrar of Companies,
______________________
______________________
______________________

Dear Sir,
Sub: Registered office of ________________________________________ Private Limited,
under registration
Ref: SRN ..filed for incorporation.
This
is
to
inform
you
that
the
premises
...., is owned by me. A
documentary evidence for the same is attached. The premises is leased to Mr.
..who is going to be the First Director of
_________________________________________________________Private Limited, under
registration. A copy of the lease deed is enclosed.
Further, I wish to express my NO OBJECTION to have these premises as registered office of the
proposed
company
__________________________________________________________Private Limited and
request you to register this address as the registered office address of the said company under
incorporation.
Thanking you,
Yours faithfully,

Owner of the property

Place:
Date:

Page | 14

POWER OF ATTORNEY
We, the undersigned subscribers of Memorandum and Articles of Association of
_______________________________________________________________________________________Private Limited, under
registration, do hereby authorize Mr. Sanjeev Kumar, Advocate & Mrs. Amrita Chanchal, Advocate &
Mr Vijay Kumar Bhasin, Company Secretary & Ms. Manisha Nanda, Chartered Accountant having their
office at K-66, Hauz Khas Enclave, New Delhi and also at 148, 4th Block Koramangala, Bangalore to
represent us and for carrying out the necessary corrections, additions, deletions, etc., in the
Memorandum and Articles of Association and in the documents filed for registration of the said
company as may be necessary and incidental thereto and to obtain the Certificate of Incorporation
on our behalf.

Name and Signatures of subscribers:

1.

Signature of (POA Holder)

Place:
Date:

Page | 15

We, the several persons, whose names and addresses are subscribed, are desirous of being formed
into a company in pursuance of this Memorandum of Association, and we respectively agree to
take the number of shares in the capital of the company set against our respective names
Sl.
No

Names, addresses,
descriptions and
occupations of subscribers

No. of shares
taken by each
subscriber

Date:

Signature
of
subscriber

Signature, names, addresses,

descriptions and occupations
of witnesses

Place:

Photograph of Subscriber
________________________

Page | 16

Sl.
No

Names, addresses, descriptions and

occupations of subscribers

Signature of
subscriber

Date:

Signature, names, addresses,

descriptions and occupations
of witnesses

Place:

Photograph of Subscriber 1
________________________

Page | 17

APPLICATION FOR DIGITAL SIGNATURE CERTIFICATE - FOR INDIVIDUAL

(For Signature Application only)

Application ID Number (For office use only):

(For Encryption Application only)

Instructions:
1. Please fill the form in BLOCK LETTERS and (*) MARKED Fields are Mandatory.
2. Inconsistent/incomplete applications are liable to be rejected.
3. (**) Attestation of documents by any: Gazetted Officer OR Bank Manager OR Post Master OR present originals to our Registration Authority for verification & attestation.
4. All subscribers are advised to read Certification Practice Statement and subscriber agreement of eMudhra available at www.e-mudhra.com
5. At par cheques/Demand draft drawn in favour of eMudhra Consumer Services Limited payable at Bangalore
6. All customer documents need to be self attested by the customer over and above the third party attestation
7. For Class III Digital Signatures In Person Verification of the applicant is mandatory

1A. CERTIFICATE CLASS*

1B. CERTIFICATE TYPE*

2. CERTIFICATE VALIDITY*

Affix
recent passport
photograph of the
applicant duly
signed across

3. USB TOKEN*

Class 1 Silver Individual

Signature

1 Year

Required

Class 2 Gold Individual

Encryption

2 Years

Not Required

Class 3 Platinum Individual

APPLICANT DETAILS* (As per applicant's valid ID Proof and Address Proof at SI.No.1 & 14 below)
4. Name:* Mr./Ms./Dr.

F I R S T N A M E
D D
M M Y Y Y Y 6. Gender:*

5. Date of Birth:*

M I D D L E N A M E

Male

Female

L A S T N A M E

7. Residential Status:*

8. Father/ Spouse Name*:

Resident

9. Nationality I N D I A N

10. eMail ID* (Valid and active E-mail ID to be included in the Digital Signature Certificate)
11. (++) Address for communication :

Residence

Office

(As per proof Submitted)

(Door No., Name of the premises, Road, Area, City, State and Pin code needs to be filled)

Pincode

City

State

Telephone No. (e.g. +91-80-23333333)

Mobile No. (e.g. + 91-9999999999)

Check list for IDENTIFICATION and DOCUMENTATION DETAILS*

Attested copy of PAN Card is mandatory for obtaining Certificate with PAN

12. PAN Number :

Passport

13. Valid Identity Documents : *

Copy of Driving License

PAN card

Post Office ID Card

Aadhaar Card

Bank Account Passbook containing the Photograph and signed by an individual with attestation by the concerned Bank official
Photo ID Card issued by the Ministry of Home Affairs of Centre/State Government
Any Government issued photo ID Card bearing the signature of the individual
(Please tick any one and fill the ID number and attach attested (**) copy of ID proof)
14. Valid Address Proof Documents : *

a) Telephone Bill

b) Electricity Bill

ID Proof Number:
c) Water Bill

f) Bank Statements signed by the Bank

g) ServiceTax /VAT/Sales Tax registration certificate

i) Driving Licence

k) Passport

j) V oter ID Card

d) Gas Connection

e) Aadhaar Card

h) Property Tax/Corporation/Municipal corporation receipt

l) Certificate of Registration for owned Vehicle

(Please tick any one and fill the Document number and attach attested (**) copy of address proof) Doc No. ___________________________________________
Note: For A to E the date of last transaction should not be older than 3months, for S.No. F & G the same should be pertain to the current financial year.
All documents should have the complete address for the purpose of accepting the same as proof.
15. Payment Details : Cheque / DD No.
Date

D D

Other Modes : ___________________________

M M Y Y Y Y

Amount Rs.

Bank: _________________________________________________________________

DECLARATION*
I hereby agree that I have read and understood the provisions of e-mudhra Certification Practice Statement (CPS) and the subscriber agreement and will abide by the same. The information
provided in this Digital Signature Certificate request form is true and correct to the best of my knowledge and I accept publishing my certificate information in e-Mudhra repository.
Date:
Place:
Seal & Stamp [If available]:

Signature of the applicant

TO BE FILLED BY RA OFFICE ONLY*

I declare that the applicant has provided correct information in this application form. I have checked and verified the application form and supporting documents.
RA Code & Name/ Seal :

Date:

Place:

Signature:

CONTACT DETAILS :
eMudhra Consumer Services Limited, 3rd Floor, Sai Arcade, 56 Outer Ring Road, Deverabeesanahalli, Opp Intel, Bangalore 560 103. Karnataka
Phone : +91 80 4336 0000 Fax : +91 80 4227 5306 Email : [email protected] Website: www.e-Mudhra.com
CONFIDENTIAL
Version 1.3

FormNo.49A
ApplicationforAllotmentofPermanentAccountNumber
[InthecaseofIndianCitizens/IndianCompanies/EntitiesincorporatedinIndia/
UnincorporatedentitiesformedinIndia]
Undersection139AoftheIncomeTaxAct,1961
Toavoidmistake(s),pleasefollowtheaccompanyinginstructionsandexamplesbeforefillinguptheform

Assessingofficer(AOcode)
Areacode

Sign/leftTumbimpressionacross
thisphoto

AOtype

Rangecode

AONo.

Sir,
I/Weherebyrequestthatapermanentaccountnumberbeallottedtome/us.
I/Wegivebelownecessaryparticulars:

1 FullName(Fullexpandednametobementionedasappearinginproofofidentity/addressdocuments:initialsarenotpermitted)

D asapplicable

Pleaseselecttitle,

Shri

Smt.

Kumari

M/s

LastName/Surname
FirstName
MiddleName

2 Abbreviationoftheabovename,asyouwouldlikeit,tobeprintedonthePANcard

3 Haveyoueverbeenknownbyanyothername?

Yes

No

Smt.

Kumari

Male

Female

(Pleasetickasapplicable)

Ifyes,pleasegivethatothername

D asapplicable

Pleaseselecttitle,

Shri

M/s

LastName/Surname
FirstName
MiddleName

4 Gender(forIndividualapplicantsonly)

(Pleasetickasapplicable)

5 DateofBirth/Incorporation/Agreement/PartnershiporTrustDeed/FormationofBodyofindividualsorAssociationofPersons
Day

Month

Year

6 Father'sName(Only'Individual'applicants:Evenmarriedwomenshouldfillinfather'snameonly)
LastName/Surname
FirstName
MiddleName

7 Address
ResidenceAddress
Flat/Room/Door/BlockNo.
NameofPremises/Building/Village
Road/Street/Lane/PostOffice
Area/Locality/Taluka/SubDivision
Town/City/District
State/UnionTerritory

OfficeAddress
Nameofoffice
Flat/Room/Door/BlockNo.
NameofPremises/Building/Village
Road/Street/Lane/PostOffice
Area/Locality/Taluka/SubDivision
Town/City/District

Pincode/Zipcode

CountryName

State/UnionTerritory

Pincode/Zipcode

8 AddressforCommunication

CountryName

Residence

Office

(Pleasetickasapplicable)

9 TelephoneNumber&EmailIDdetails
Countrycode

Area/STDCode

Telephone/Mobilenumber

EmailID

10 Statusofapplicant
Pleaseselectstatus,

D asapplicable

Government

Individual

Hinduundividedfamily

Company

PartnershipFirm

AssociationofPersons

Trusts

BodyofIndividuals

LocalAuthority

ArtificialJuridicalPersons

LimitedLiabilityPartnership

11 RegistrationNumber(forcompany,firms,LLPs,etc.)
12 IncaseofacitizenofIndia,then
PleasementionyourAADHAARnumber(ifallotted)

13 SourceofIncome

Pleaseselectstatus,

Salary

D asapplicable

CapitalGains

IncomefromBusiness/Profession

Business/Professioncode

[ForCode:Referinstructions]

IncomefromHouseproperty

IncomefromOthersources
Noincome

14 RepresentativeAssessee(RA)
Fullname,addressoftheRepresentativeAssessee,whoisassessableundertheIncomeTaxActinrespectoftheperson,whoseparticularshavebeengiveninthe
column113.

FullName(Fullexpandedname:initialsarenotpermitted)
Pleaseselecttitle,

D asapplicable

Shri

Smt.

Kumari

M/s

LastName/Surname
FirstName
MiddleName
Address
Flat/Room/Door/BlockNo.
NameofPremises/Building/Village
Road/Street/Lane/PostOffice
Area/Locality/Taluka/SubDivision
Town/City/District
State/UnionTerritory

Pincode

15 DocumentssubmittedasProofofIdentity(POI)andProofofAddress(POA)
I/Wehaveenclosed

asproofofidentityand

asproofofaddress.
[Pleaserefertotheinstructions(asspecifiedinRule114ofI.T.Rules,1962)forlistofmandatorycertifieddocumentstobesubmittedasapplicable]

16 I/We
doherebydeclarethatwhatisstatedaboveis

,theapplicant,inthecapacityof
truetothebestofmy/ourinformationandbelief.

Place
D
Date

D M M

Signature/LeftThumbImpressionof
Signature
/ Left Thumb Impression of
Applicant(insidethebox)

Form No. 49B

[See section 203A and rule 114A]

Form of application for allotment of Tax Deduction and Collection Account Number
under Section 203A of the Income Tax Act, 1961

To,

Assessing Officer (TDS / TCS)

.....................................................
.....................................................
Assessing Officer Code (TDS / TCS)
Area code
AO Type
Range Code
AO Number
Sir,
Whereas *I/we *am/are liable to *deduct/collect or deduct tax and collect tax in accordance with Chapter XVII under the heading *B. Deduction
at source or 'BB. -Collection at source' of the Income-tax Act, 1961;
And whereas no Tax Deduction Account Number/Tax Collection Account Number or Tax Deduction Account Number and Tax Collection Account
Number has been allotted to *me/us;
*I/We give below the necessary particulars:
[ Please refer to instructions before filling up the form ]
1 Name - (Fill only one of the columns a to h, whichever is applicable.)
(a) Central / State Government:
Tick the appropriate entry

Central Government

State Government

Local Authority (Central Govt.)

Local Authority (State Govt.)

Name of Office

Name of Organisation

Name of Department

Name of Ministry

Designation of the person responsible

for * making payment / collecting tax
(b) Statutory / Autonomous Bodies :
Tick the appropriate entry

Statutory Body

Autonomous Body

Name of Office

Designation of the person responsible

for * making payment / collecting tax

V.1.1

Name of Organisation

(c) Company (See Note 1) :

Tick the appropriate entry
Title (M/s)

Government Company/Corporation
established by a Central Act

Government Company/Corporation
established by a State Act

Government Company/Corporation
established by a Central Act

Government Company/Corporation
established by a State Act

Other
Company

(tick if applicable)

Name of Company

Designation of the person responsible

for * making payment / collecting tax

(d) Branch/Division of a Company:

Tick the appropriate entry
Title (M/s)

Other
Company

(tick if applicable)

Name of Company

Name of Division

Name/Location of Branch
Designation of the person responsible
for * making payment / collecting tax

(e) Individual / Hindu Undivided Family (Karta) - (See Note 2) :

Tick the appropriate entry

Hindu Undivided Family

Individual

Title (tick the appropriate entry for individual)

Shri

Smt.

Kumari

Last Name / Surname

First Name
Middle Name
(f) Branch of Individual Business (Sole proprietorship concern)/ Hindu Undivided Family (Karta)
Tick the appropriate entry

Branch of Individual business

Branch of Hindu Undivided Family

Individual/ Hindu Undivided Family (Karta):

Title (tick the appropriate entry for individual)

Shri

Smt.

Kumari

Last Name / Surname

First Name
Middle Name
Name/Location of branch
(g) Firm / Association of Persons / Association of Persons (Trusts) / Body of Individuals / Artificial Juridical Person (See Note 3) :
Name

(h) Branch of Firm / Association of Persons / Association of Persons (Trusts) / Body of Individuals / Artificial Juridical Person:
Name of Firm / Association of Persons / Association of Persons (Trusts) / Body of Individuals / Artificial Juridical Person:

Name/Location of branch
2 Address
Flat / Door / Block No.
Name of Premises / Building / Village
Road / Street / Lane / Post Office
Area / Locality / Taluka / Sub-Division
Town / City / District
State / Union Territory
PIN code
Telephone No.
e-mail IDs

STD Code

Phone No.

a)

b)

3 Nationality of Deductor (Tick the appropriate entry)

Indian
Foreign
4 Permanent Account Number (PAN) - (specify wherever applicable)

5 Existing Tax Deduction Account Number (if any)

6 Existing Tax Collection Account Number (if any)

7 Date (DD-MM-YYYY)
-

Signed (Applicant)
Verification
*I/We,.. in my/our capacity as.do hereby declare that what is stated above is true
to the best of my/our knowledge and belief.
Verified today the

d d

m m

y y

at ...

..........................................
(Signature/Left Thumb Impression of Applicant)

Notes :
1 This column is applicable only if a single TAN is applied for the whole company. If separate TANs are applied for different
divisions/branches, please fill details in (d).
2 For branch of Individual business/Hindu Undivided Family, please fill details in (f).
3 For branch of firm/Association Of Persons/Association Of Persons (Trust) / Body Of Individuals/Artificial Juridical Person,
please fill details in (h).
4 * Delete whichever is inapplicable.