TO WHOM IT MAY CONCERN

Applicant Details

Surname/Last Name: _________

First Name: _________

Middle Name: _________

Date of Birth: _________

Specimen Signature/Thumb Impression

Father Details: _________

Surname/Last Name: _________

First Name: _________

Middle Name: _________

Date of Birth: _________

Residence Address: _________

This is to certify that the above mentioned details are true to my knowledge and this certificate is obtained for the purpose of obtaining PAN Application.

Date: _________                        Seal & Signature

Note:  This Pan Card Affidavit to be used if no address proof available to be attested by Gazetted Officer and this application form also  have a attested photo pasted on it (Subject to Acceptance of Pan Card Authority).