NATIONAL PENSION SYSTEM (NPs)- su SCRIgER REGISTRAT9N URE

Central Recordkeeping Agency (CRA) - NSDL [Link] inirastructure Limited

Piease seiect your category Central Govt. State Govt.
Please tick()) AllCitizen Model Corporate Sector NPS Lite (GDS)
To,
Nalona Peruson System Trust 30v|304 6
Dear Si/Madam,
WA/up
Ihereby request that an NPS account be opened in my name as per the
particulars given below: y444SYy
indicates mandatory fields. Please fillthe fonn in English and BLOCK letters with black ink pen. (Reler general guidefines at instrucions page)
KYC Number, Rottrement Adviser Code and Spouse Name flelds are not appllcable for
Government & NPS Lite Subscribers
KYC Number (if applicable) IGenerated from Central KYC Registry
Retrement Adviser Code (It applcabie)
1. PERSONAL DE TAILS: (Please refer to Sr.
No.1 of the instructions)
Name of Appiicant in full Shri Smt. Kurmari
First_Name ReiA vieleN
Middie Name
Last Name
Subscriber 's Maiden Name (it any)
Father's Name
(Reler St No 1of instnuctions)
Mother's Name*
(Refer Sr. No. 1of instructions)
Father's name willbe pninted on PRAN card. In case, mother's name to be printed instead of father's narhe [ Please tick ())
Date of Sirth
City of B1rth
291i993: (Date of Birth shouid be supported by relevant documentary proof)

Country of Birth A
Gender [Please tick () ) Male n Female Others Nationality In-indian
Marital Status* Married Unmarried Others
Spouse Name*
(Reler St No 1of instruciions)
Residential Status" Indian

2. PROOF OF IDENTITY (Pol)" (Any one of the documents need to be provided along with the identification numbe:)
Passport Passpot Expiry Date
Voter ID Card : PAN Card
Driving License Driving License Expiry Date
NREGAJOB Card
Others Name cf the ID Plezse re'e: Sr. No. 2 of tne insirudiora

UID (Aadhaar)
lhereby authorize CRA registered with Pension Fund Regulatory and Development Authonity (PFROA)to use my Aadhaar details for National Pension System (NFS)
and authenticate my identity through the Aadhaar Authentication system (Aadtaar based e-KYC sevices of UIDAI) in accordance with the provicicns of tre Aadhaar
tified thereusder. I understand trat the
(Targeted Delivery of Firancial and other Subcidies, Benefits and Services) Act. 2016 and the alied rules and regulations notiffe Ves tit the time the acoJunt is not
Aadhaar details (physical and /or digital, as the case maybe) subrmitted for avaiing services under NPS will maintained in NP.
inactive in NPS or the timeframe decided by PFRDA, the regulator of NPS, whichever is later. I understand that Security and contidentialityof perseral identity gata
provided. for the purpose of Aadhaar based authentication is ensured by CRA registered with PFRDA till such time it is acting as CRA for my NPS accrunt.
As perthe amendments made under Preventionof Money-Launcering (Maintenance of Fecords) Secand Amendment Rules. 2017 Aadhaar and PAN are tiancatory under NPS.
f vouto not have 42dhaer and /or PaN at oresent, ole2seensure that these details are orovided within six mcnths of submission of this Subscriber Regictratior Fom.

3 PROOF CF ADDRESS (POA Correspondence Address Pemanent Address

(Please tick (). as applicable Passport /Driving License/UID (Adhaar)/Voter ID card/NREGA Job Passport Driing LicenseiUID (Aadhsar)Vcter (D card/NREGA Jcb
Card/Ralion Card/Others Card/Raion Card/Others
#Not mare than 3 mont!hs old
Piease refer Sr. No the instruclions Registered Lezse/Sale agreement of residence Reqistered LeaseiSale agreement af residence
Latest Gas/Electncity/ TelephorelLandline) Bill #Lalest GasiElecticty Telephone[Landline) Sil
4.1 CORRESPONDENCE ADDRESS DETAILS
Residential/Business Residential Business Registered Office Unspecified
Address Type
FlaURoorn/Door/Block no. No:i6 Landmark

Premises/Building/Village 5FA
Road/StreetLane
Area/Locality/Taluk |1|6
PIN Code
City/Town/District
State/U.T.

4.2 PERMANENT ADDRESS DETAILS Tck () inthe box in case the address is same as above.
Address Type Residential/Business Residential BusinessRegistered Office Unspecified
FlatRoom/Door/Block no. |NI. 35 Landmark

Premises/BuiltdingViliage LL A n !- 1SAuN A
Road/Street/Lane
ArealLocality/Taluk
City/Town/District PN Code 2 G495
StateU.T. Alkh iAN
 CONTACT DETAILS
Tel io (with $T0 code) Tei. (Res): (vit: STD code

iviobile (iviandatcryi 750553272 (iobile Number is required for communication and to get SMS a
Email ID Prav ee n ana120o qmo corm P i e a s e

OTHER DETAILS IPlease refer to Sr no, 3 of the instructions )

Occupation Details [please tick()]
Private Sector Public Sector Government Sector Professional
Self Employed Homemaker Student Others (Please Specify)
incame Range (per annum) Upto 1 lac 1lac to 5 lac 5 lac to 10 lac 10 lac to 25 lac 25 lac and above

Educational Qualifications Below SSC SSC HSC Graduate ZMasters Professionals ( CA. CS,.CMA etc.)
Piease Tick If Applicable Politically exposed person Related to Politically exp0sed Person (Please refer instruction no.3)
7 SUBSCRIBER BANK DETAILS (Please refer to Sr no, 4 of the instructions )
(AJIthe bank detai!s are mandatory except MICR Code.)
Account Type ple ase tick() Savings Alc Current A/c
Sank Ac Number
923o o o I 4 ! | 5 6!5.3
Bank Name AX |Si ß'A:NK
Branch Name [Link]!E is w A RA M AANGA
Branch Address
2 3 3 2Nl o O lzl PIN COde 56 o
A.0: iM.A L L E s wA!kA
Bank MICR Code
S:6 O 2 | i O0 4 IFS Code
8. SUBSCRIBERS NOMINATION DETAILS" (Please refer to Sr. No.5 of the instructions)
NameOi ie ivOTIies tiou car. ronnale up io a T:im J . nominess and i ro desire so ple2se fl! in Anneue Ift (additional Nomination Fom) provided separatelv!
First Name Middie Name Last Name
RAJ ESh wARI 0EViL
Relationship with the Nominee
" M0TMER Date of Birth (ln case of Minor)

.Nominee's Guardian Details(in case of aminor)

First Name Middle Name Last Name

9. NPS OPTION DETAILS (Please tick () as applicable)

Iwould like to subscribe far Tier Il Account also YESNO Yes; pleasesubmit details in Aanexure I.
(1f you wsh to activale Tier il account subsequently, you may submit separate application (Annexure S10) to the associated Ncdal Office or to POPPOP. SF of vour choice. Tha ist ef POPr
POP-SPs rendering services under NPS and Annexure S10 is available on CRA website)
Iwould lEke my PRAN to be prihted in Hindi YES NO If Yes, please submit details on Annexure I|

10. PENSION FUND (PF) SELEÇTION AND INVESTMENT OPTION* (Please refer to Sr no. 6 of the instructions )
(i) PENSION FUND SELECTION (Tier I):Please rad below conditions before opting for the choice of Pension Funds:
1 Government Sector. For Govermment Subscribers, the following PFs açt as default PFs as per the guidelines issued by the Govemment:
aitFans,cn Func - u (3 sI ensicn Funcs Pvt. LIMited (a; UTi nanremeri Scunons LiC.
AlCirizen ioce!: Sups cribers under AlI Citzer. modet nave ihe opion to choose the avaiiable PFs as per iheir chcice in the tale Delow.
Corpoate Model: Subs cribers shall have the option to choase lhe available PFs as per the below tabie in consultalion with their respecive Enpiover
4 NES Lite: NPS Lite is a group choice model where subscriber has a choice of PF and investment option 2s available with Aggregator.
Name of the Pension Fund (Please select only ane) Please Tick () Availability of the Psnsicn Funds
LIC Pension Fund Limited
Available to
SBIPension Funds Private Limited Government
^ector
UTI Retirerment Solutions Limited
ICICI Prudential Pension Funds Management Company Limited Available to Available to A!! Available
NPS Lite Citizen Moder Corporate
Kotak Mahindra Pension Fund Limited Modal
Reliance Capital Pension Fund Limited

HDFC Pension Management Company Limited

Birla Sunlife Pension Management Limited

" Selection of Pension Fund is mandatory both in Active and

Auto Choice'

(in) INVESTMENT OPTION

(Please Tick () in the box given below showing your investment option).
Acive Chcie Aulo CiiLa
Fiedse noie:
select Auto Choice fill up section (iv) below.
1. in case youselect Active Choice fil up section (ii) below and if you
option, yoUr funds will be invested in Auto Choice (LC 50).
2 In case you do not indicate any investment investent will
case you have opted fcr Auto Choice and fill up section (ii) below relating to Asset Allocation, the Asse! Allocation instructions will be ignored and
3. In
be made as per Auto Choice (LC 50).

2 of 5
 ACTIVE CHOICE - ASSET
ALLOCATION (to be filled up onty in case you have
selected 'Actlve Choice' the
Acco! Cas investment option)
exceed 75%) 100%) 100%) Talg! Acce! clas: EEçuisy 3nd ela'ed
exceed 5%) irstruments Agse! dass [Link] negt and
instruments: Assel class G-Coverment
Speaiy % Bords and related instruments ralaled
100%
A-Altemative Investment Funds including insiruments like
Asset Ciass
CMBS, MBS, REITS AIFs, Invtts etc.
Please note:
1 Upto 50 years of age. he
2 From 51 years and above,
maximum permitted Equity Investment is 75% of the
lolai asset
allocation will be caried out maximum permitted Equity Inveslment will be as per the allocation.
as per the matix on
date of birth. equity allocalion matrix provided in
3. The tolal
allOcation across E, C,G and Aassel Annexure A. The tapering ol equity
be rejected. classes must be egual to 100%. In case. the
allocation is left blank and/or does not equal
(iv) AUTO CHOICE 100%. the appication shai
a choice of LC, OPTION (to be filled up oniy in case you have
yaur funds will be invested as per
LC 50,
selected the 'Auto Choice'
investment option). In case, you do not indicato
Dlanee Tirk (lOnlv One
LC 75
Nole: 1. LC75- It is the Life cycle
fund where the Cap to Eguity
LC S0 2. LC 50- Il is the Life cycle
fund where the Cap to Equity
invesiments is 75% of the total asset
LC 25 3. LC 25- It is the Life cycle fund investments is 50% of Ihe total asset
where the Cap to Equity investrments is 25%
of the total asset
11. DECLARATION ON FATCA* (Foreign Account Tax
Section * Compliance Act) COMPLIANCE (Please refer to Sr no. 7of the instructions):
US Person Yes No

Section |*
Fe the puiposes i ianatio, Iar e
out below or Ihave indicated that a iEsident ir the íoliowing countries and my Tax
TINfunctional eguivalent is unavailable (indly ldeniicaion Number (TIN)/functional equivalent in eacri
fill details of all countries of tax residence if touriy Is set
more than one):
Particulars
Country (1) Country (2)
Countryicountries of tax residency Country (3)

Address Line 1
Address in the jurisdiction for Tax
Residence City/+ownVillage
Siaie

ZIP/Post Code
Tax ldertification Number (TIN)/Functional eguivalent Number
TIN/ Functional equivalent Number Issuing
Country
Valiaity of doçumentary evidence provided (Wherever
applicable)
" certifv that:
a) It shall be mv resoonsibility to educate
mvself and to comply at all times with all relevant lawS relating to
Mit he Fuies TI4F o 114E ai tne income tax
RLles. 1302 irerecncer and tne iríormaior reporting under section 2853A of the Act read
ruies. sroviGeC in ne Forn is in [Link] witr the arcresac
b) the information provided by me in the Form, its
supporting
belief. true, coect and complete and that | have not withheldAnnexures
as well as in the documentary evidence are. to the
best of my knowiedçe and
any material infomation that mav affect the
aReportable account or otherwise. assessmentcategorization
of the account as
c) Ipermit/authorise the NPS Trust to collect, store,
communicate and process information relating to the Account and all
Trust and any of NPS intermediaries wherever situated
including sharing, transfer and disclosure between them and to transactions therein, by the NPS
the authorities in and!or outside
India of any confidential information
for compliance with any law or
d) Iundertake the responsibility to declare and disclose regulation whether domestic or foreign.
within 30 days from the date of
provided in the Form, its supporting Annexures as well as in the documentary evidence change, by any changes that may take place in the informatian
províde fresh self-certification along with documentary evidence, provided me or if any certification becomes incorrect and to
e) lalso agree that in case of my failure to disclose any material fact
known to me, now or in future, the
authority designated by the Govemment of India (GOl) /RBIIRDAPFRDA for the purpose or take anyNPS Trust may report to any requlator and/or any
the NPS Trust if the deficiency is not remedied by me within the other action as may be deemed appropriate by
stipulated period.
f lhereby accept and acknowledge that the NPS Trust shall have the right and
authority to cary out investigations from the infonation available in pubiic
dornain for conñrming the infornation proviged by me to the NPS Trust
a) lalso agree to furnish such information and/or documents as the NPS Trust may
require from time to time on account of any change in law either in
India or abroad in the subject matter herein.
h) lshall indemnify NPS Trust for any loss that may arise to the NPS Trust on account of providing incorrect or incomplete information.

Date 3o!o:6! 20!23

Place :
Signature/Thumb Impression of Subscriber in biack ink
(°LT in case of male and RTI in case of females)
Name of subscriber

3 oi 5
 12. DECLARATION 3Y sUESCRIBER (Flesse refer to St ne 8af the irsiructions ) Authorisatio
sub
the
deci
Declarstion & Authorization bu all subscribers
PFRDAAc! that
Nalional Pension Systerm and hereby agree to the same along vilh the yndertake to
have reaC and ucarslood the terms anc canditions cf the
and correct, lo the best of Ty knowledge and belief. I .infom
regulations ames
fran imed
above
Ove
and declare
Record that the
Keeping intormation and
Agency/Nalional documents
Pension Svstem Tust. by
fumished me are true
immedialeh
of any change in the above information furnished by me. I do not hold'any pre-ex1stine account
Understand that lshall be fulv liabie for submissicn oB any false or incorrect information or documentis.
th

and
e
read

thereof as approved by De
COmplereagree
Turher ar partial boundanv
to be without by the temms and conditions of provision of services by CRA, from time to time and any amendment
new declaration beino furnished by me. I shall be bound by the lerms and conditions for the usage of I-PIN (lo access CRAAwebsite
detals) & T-PIN.
Declaratlon under the Preventlon of Money Laundering Att, 2002
I hereby declare that the contribution paid I by melon my behalf has been derived from legally declared and assessed sources of income. I understand that NPS Tust ha
G tgntro penuse my fnanciai proñte or share the infomation, with other govemment authorities. Ifurther agree Ihat NPS Trust has the ngnt lo close my PRAN in Ca ias
tound iolatiËng the provisions of any law relating to prevention of money laundering.
Date
207oG2023|
Dlaan
BANh LurE
Signature/Thumb Impression of Subscriber in black ink
(°LTI in case cf male and RTI in case of females)
13. DECLARATION BY
EMPLOYER
Applicable to Government Subscribers only
(Subscribers Employment Details to be filled and attested by the Deptt. (AllDetails are Mandatery)
Date of Joining 29. o 6 2 o23 Date of Retirement 30 1 | i 2053
Employee Code/lD (lf applicable) Empioyee Code/1D and PPAN are opiona. If you intend
PPAN (f applicable) to pruvide, mention any cne.
Group of Employee (Tick as applicabie) Group A Group B Group C Group O
Ofice

Department MEC HANTC A:L!

Ministry LWA y.
DDO Registration Number
DTO/PAOICDDODTAPrAO Registration Number
Basic Pay
Pay Scale |1 O:0
It is certifñed that the details,provided in this subscriber registration form by employed with us, including
tne adaress and empioyment details provided above are as per the servicerecord, gf th¹ employee miaintained by us. Ålso, i is furtiei cartiied that
he/she has read entries/entries have been read over to him/her by us and got confirmed by him/her.

Signature of the Authorised person Rubber Stamp of the DDO Signature of the Authonsed person Rubber Stamp of the DTO/PAO/CDDO
(In the box above) (tn the box above) (In the box above) DTAPrAO (In tre box above)
.Deslgnation of the Authorised Person Designation of the Authcrised Person
Name oi the DDO Name of DTOPAOICDDO/D TAPrAO
Deptt/Ministry Date

14. DECLARATIONBY EMPLOYER/ CORPORATE

Appicable to Corporate Subscribers anly
(Subscribers Employment Details to be filled and attested by Corporate (AllDetails are Mandatory)
Date of Joining Date of Retirement

Empioyee Code/D
Corporate Regd. Number (CHO No.) Allotted by CRA

C8O No., allotted by CRA

Certiied that the details provided in this subScriber registration form by empioyed with us, including the
emplovrment details provided above are as per the service record of the employee maintained by us. Also, it is futher certified that he / she has read the
entries /entries have been read over to him /her by us and got confirmed by him / her.
Place
Date |

Signature of the Authorised person (ln the box above)

Designation of the Authorised Person Rubber Stamp of the Corporate (ln the box above)

4 of &
by
P c ount undiezCrtiealy ned
trie y C
£CLARATION SY THE AGGREGATOR

PFRDA whe
Authorisation by Aggregator's office (NL -ÀO)
Åppicable to iýPS Lite Subscribers

Certied that the subsciber is registered with the aggregator and he/she has opted to join NPS. Ihereby declare that the subscriber is eligibie to join NPS
and the above decdaration has been signed /thumb impressed before me by ... .after (s)he has read the entries/ eniries have
been read over to her/him by me.

Signature of the Authorised person (ln the box above) Rubber Stamp of the Aggregator (In the box above)
Name of the Aggregator

NPS Lite Account Ofice (NL-AO) Registration Number

NPS Lite Collection Centre (NL CC) Reaistration Number
Membership No. allotted by Aggregator (if any)
Place Dale

16. TO BE FILLED BY POPSP

Receipt No. (17 digits) POP-SP Registration Number

Document accepted for date of Birth Proof:

Copy of PAN card submitted YES NO KYCCompliance YES NO

Documents Received: (Originals Verified) Self Certiñed (Atesied) True Copies
ioentily veriñcaüon. Done

Existing Bank Customer:

l/we hereby certify/confirm that Shi/Smt/Kum
Saving Bank account no. ..is an existing customer of the Bank having fully operative
. ..at.
..branch and KYC nomms required for openingBank Account
which match the requirements tor opening NPS account have been fully complied with. We further contirm that the S. B. alc of Sh/SmtiKum
is not a 'Basic Savings Bank Deposit Account'
Adhaar Based KYC Certificate:
/we hereby certify that Aadhaar Number ..of Sh/Smt/Kum. .has been checked and the name
and agaress mentioned on the orig1nal Aadhaar card are matching witn tnat mentioned on NPS appication form.

73 be fiiec by P0F-SP
Name:

Designation: Place:

POP-SP Seal Signature of Authorized Signatory Date

[To be filled by CRA - Facilitation Centre (CRA-FC)]

Received by CRA-FC Registration Number

Received at Date

Acknowledgement Number (by CRA-FC)

PRAN Alloted

ACKNOWLEDGEMENT
Name of the Subscriber:

Contribution Amount Remitted:

Date of Receipt of Application and Contribution Amount:

Stamp and Signature of the Employer/PoP:

5 of 5
 Government of India

Praveen Singh
yn faf/DOB: 29/11/1993
qe/ MALE

6750 2574 8838

VID 9171 7988 8797 6953

Ader
3o/os/
2o3

Unique tdentification Authoritly of India

S/O R RE, ucsr .06 F=06 ART
ttsRhdi-1l, 1 16-41, aro,
fi- 110078
Address:
S/O Rajinder Singh, QTR NO-06 SFA NO 06
SFA SSB QTR PKT-1, SEC 16-8. DWARKA.
N.S.I.T Dwarka, South West Delhi.
Delhi - 110078

6750 2574 8838

VID.9177 7988 8797 6953
 OVT O INDIA
INCOME TAZ DEPAKTMENT

KSDPST469N

PHAVEEI 61

HAJIWER

99/11/199%
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