Annexure -A (Certificate to be used by a Member of Parllament/Member of Legislative Assembly/Municipal Councillor Gazetted Officer under sub-rule (4) of rule 114 ofthe Income-tax Rules, 1962) A ae tera affised on PAN application fom To be ate by Tg ator ith hisher signature & rubber stamp appearing half onthe ‘photograph and half om the cordate) Thereby certify that I know Sh./Smt/Kum ee . son/daughter of v.20... _and his/her personal particulars as given below are correct to the best of my knowledge and belief. I recommend issue of PAN card by the Income-tax Department to him/her. Name Father's Name (even in ease of married ladies father’s name sto be provided) Date of Birth Residence Address (ifapplicant has resided at more thaw one Office Address, Previous Name (in case of change ia name) Details of issuer of certificate (Signature) Office address with location Full Name: Designation: Office Seal Department/Organization/Constituency: Identity card No: Date (Enclose « photocopy of card) Place: Telephone: Mobile: