NATIONAL PENSION SYSTEM (NPS) SUBSCRIBER REGISTRATION FORM

To
The National Pension System Trust
Dear Sir/Madam,
I hereby request that an NPS account be opened in my name as per the particulars given below, please fill the formin English and BLOCK letters
with black ink pen.

National Pension System (ONLY FOR PHOTO SIGNATURE UPDATION)

Category(All fields are All India Citizen Model

mandatory)
Name of the customer ROHIT PANDEY
Date of Birth 14-05-1985 Affix recent
Gender MALE passport
Father’s Name SHRIDHAR PANDEY photograph
Mother’s Name NIRMALA PANDEY
City of birth Mauranipur
Country of birth INDIA
Residential status Resident Indian
PAN No. ( ID Proof) AJQPP9763L
Mobile No. 9028909988
Email ID [email protected]
Aadhar No
Occupation Details Salaried
Marital Status MARRIED
Spouse name Kamya Dubey

1001,RIVER RESIDENCY PH-3

N2,10TH FLR,, 412105 Bank Type Savings
Address Account No. 098601517542
( Correspondence Bank Name ICICI Bank
Address is same Branch Address SHOBHA GUEST HOUSE ,HINJEWADI PH II PUNE
as permanent Pin Code 411057
Address
State MAHARASHTRA
Country INDIA

Nominee Name Aadrit Pandey PFM ICICI Prudential Pension Fund Management Co. Ltd

Relationship Investment
SON Active Choice
with Nominee Option
DOB 04/07/2019 Asset
Equity 50, Corporate 25, Government 25
Nominee Allocation
Rohit Pandey
Guardian Branch
SHOBHA GUEST HOUSE ,HINJEWADI PH II PUNE
Subscription NO Address
for Tier II POP SP No. 6327252
Print PRAN in NO
Hindi

ASSET ALLOCATION (to be filled up only in case you have selected the ‘Active Choice’ investment option)
Asset Class E (Cannot exceed 50%) C (Max up to 100%) G (Max up to 100%) A (Cannot exceed 5%) Total Note: 1. The total allocation across E,
C , G and A asset classes must be equal to 100%.
In case, the allocation is left blank and/or does not equal 100%, the application shall be rejected. 2. Asset class E-Equity and related instruments;
Asset class C-Corporate debt and related instruments; Asset class G-Goverment Bonds and related instruments; Asset Class A-Alternative
Investment Funds including instruments like CMBS, MBS, REITS, AIFs, Invlts etc. Specify %
Auto Choice Option (to be filled up only in case you have selected the ‘Auto Choice’ investment option).
In case, you do not indicate a choice of LC, your funds will be invested as per LC 50.
Life Cycle (LC)Funds Please tick Note: 1. LC 75- It is the Life cycle fund where the Cap to Equity investments is 75% of the total asset 2. LC 50- It
is the Life cycle fund where the Cap to Equity investments is 50% of the total asset 3. LC 25- It is the Life cycle fund where the Cap to Equity
investments is 25% of the total asset

GS_2017_FEB_ICICI CREDITCARD_CORP_10732272_SIZE A4_NPS FORM

 Declaration by subscriber

Declaration and authorization by all subscribers

I have read and understood the terms and conditions of National Pension System and hereby agree to the same and declare that the information
and documents furnished by me are true and correct to the best of my knowledge and belief.

I further agree to be bound by the terms and conditions of provision of services by CRA, from time to time and any amendment thereof as
approved by PFRDA, whether complete or partial without any new declaration being furnished by me.I shall be bound by the terms and
conditions for the usage of I-PIN ( to access CRA/NPSCAN and view details) & T-PIN on CRA Website.

Declaration under the Prevention of Money Laundering Act, 2002

I hereby declare that the contribution paid by me/on my behalf has been derived from legally declared and assessed sources of income.
I understand that NPS Trust has the right to peruse my financial profile or share the information with other Government authorities. I further
agree that NPS Trust has the right to close my PRAN in case I am found violating the provisions of any law relating to prevention of Money laundering.

Place :-
LALITPUR

Date (DD/MM/YYYY) :- 27/02/2022 Signature of subscriber in black Ink

12. DECLARATION ON FATCA* (Foreign Account Tax Compliance Act) COMPLIANCE:

For the purposes of taxation, I am a resident in the following countries and my Tax Identification Number (TIN)/functional equivalent in each
country is set out below or I have indicated that a TIN/functional equivalent is unavailable (kindly fill details of all countries of tax residence if
more than one):
US person* No No
I have investments abroad No No

I certify that:
a) It shall be my responsibility to educate myself and to comply at all times with all relevant laws relating to reporting
under section 285BA of the Act read with the Rules 114F to 114H of the Income tax Rules, 1962 thereunder and the information provided in the
Form is in accordance with the aforesaid rules,
b) the information provided by me in the Form, its supporting Annexures as well as in the documentary evidence are, to the best of my
knowledge and belief, true, correct and complete and that I have not withheld any material information that may affect the
assessment/categorization of the account as a Reportable account or otherwise.
c) I permit/authorise the NPS Trust to collect, store, communicate and process information relating to the Account and all transactions therein,
by the NPS Trust and any of NPS intermediaries wherever situated including sharing, transfer and disclosure between them and to the
authorities in and/or outside India of any confidential information for compliance with any law or regulation whether domestic or foreign.
d) I undertake the responsibility to declare and disclose within 30 days from the date of change, any changes that may take place in the
information provided in the Form, its supporting Annexures as well as in the documentary evidence provided by me or if any certification
becomes incorrect and to provide fresh self-certification along with documentary evidence,
e) I also agree that in case of my failure to disclose any material fact known to me, now or in future, the NPS Trust may report to any regulator
and/or any authority designated by the Government of India (GOI) /RBI/IRDA/PFRDA for the purpose or take any other action as may be deemed
appropriate by the NPS Trust if the deficiency is not remedied by me within the stipulated period.
f) I hereby accept and acknowledge that the NPS Trust shall have the right and authority to carry out investigations from the information available
in public domain for confirming the information provided by me to the NPS Trust
g) I also 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) I shall indemnify NPS Trust for any loss that may arise to the NPS Trust on account of providing incorrect or incomplete information.

Date D M M
D 0
2 7 2 Y2 Y0 Y
2 2Y Signature of subscriber in black ink

Place LALITPUR

To Be Filled By ICICI Bank

We confirm that this is an existing customer of the bank having fully operative savings account no. 098601517542 at ICICI branch and KYC Norms
required for opening bank account which match the requirements for opening NPS account have been fully complied with. We further confirm
that the SB account is not a basic savings account deposit Account.