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).
