Annexure -A
(Certificate tobe used by a Member of Parliament/Member of Legislative Assembly / Municipal Councillor or
Gazetted Officer under sub-rule (4) of rule 114 of the Income-tax Rules, 1962)
fisane
‘Photograph as
Med on PAW
ication fr
THe Be asd iy suing” authority with
disher signatre & robber samp appearing
half on the photograph and half om the
certs)
muKum...
I hereby certify that | know Shy pesca pesca
..and his/her personal particulars as given
son/daughter of .. ee
below are correct to the best of my knowledge and belief. | recommend issue of PAN
card by the Income-tax Department to him/her.
Name
Father's Name
(even in case of mare ladies father's
‘name i to he provided
Date of Birth
Residence Address
aided at more than
ne year then
Office Address
Previous Name (incase of
shane in ams
Details of issuer of certificate
(Signature)
Office address with location Full Name:
Designation:
Office Seal Department/Organisation/Constituency
Identity card No.
Mobile:
IMPORTANT NOTE :
Fot Major Changes / Correction in Name or Father’s Name of Applicant, this certificate in Original is Mandatory for
PAN Application. Certificate can be attested by any Gazetted Officer /MP/ MLA. / Municipal Counsellor. Along with
‘Annexire A, photocopy of Govt Office ID Copy of the Officer who Avtests this Certificate is Mandatory.