SUBSCRIBER REGISTRATION FORM

SUBSCRIBER REGISTRATION FORM

Aadhaar based registration Non Aadhaar based registration √
Please Select your Category All Citizen Model CG/SG Sector √
NSDL eGovernance Karvy Computer
Select your Central Recordkeeping Agency (CRA) Infrastruture Ltd √ Infrastruture Ltd
To,
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 :

KYC Number
Retirement Advisor Code

1. PERSONAL DETAILS:
Name of Applicant in full Shri √ Smt Kumari
First Name * ANUJ
Middle Name KUMAR
Last Name GUPTA
Maiden Name (if any*)
Father's Name* PREMLAL GUPTA
Mother's Name* GIRJA WATI GUPTA
Date of Birth * 1 4 / 0 4 / 1 9 9 5
City of Birth * SIDHI
Country of Birth INDIA
Marital Status* Married √ Unmarried Others Gender * √ Male Female Others

Nationality* IN-Indian √

Spouse Name*
Residential Status* Indian

2. PROOF OF IDENTITY(PoI)*
Passport Passport expiry Date
Voter ID Card NVA1041326 PAN Card BLBPG3919H
Driving License Driving License expiry Date
UID (Aadhaar) High School Mark sheet

3. PROOF OF ADDRESS (PoA)*

Proof of Address Passport Driving License Aadhaar card Voter ID card NREGA Job Card Ration Card Others
Registered Lease Sale agreement of residence Property Tax Receipt Bank passbook POP Certificate
Latest Gas Bill Electricity Bill Telephone[Landline] Bill CG/SG ID Card Signed letter from class 1 officer

4.1 CORRESPONDENCE ADDRESS DETAILS*

Address Type* Residential/Business √ Residential Business Registered Unspecified

Flat/Room/Door/Block no. ARJUN NAGAR

Landmark NORTH KAROUNDIYA

Premises/Building/Village KOLAN BASTI

Road/Street/Lane WARD NO 12

Area/Locality/Taluka NEAR HARIJAN THANA

City/Town/District SIDHI PIN Code 486661
State/U.T. MADHYA PRADESH
Country INDIA

4.2 PERMANENT ADDRESS DETAILS: Tick ( ) in the box in case the address is same as above.
Address Type*
Address Type* Residential/Business √ Residential Business Registered Unspecified

Flat/Room/Door/Block no. ARJUN NAGAR

Landmark NORTH KAROUNDIYA

Premises/Building/ KOLAN BASTI
Road/Street/Lane WARD NO 12

Area/Locality/Taluka NEAR HARIJAN THANA

City/Town/District SIDHI PIN Code 486661

State/U.T. MADHYA PRADESH

Country INDIA

5. CONTACT DETAILS
Tel. (Off) Tel. (Res) : -
Mobile +917489399273
Email ID ANUJG323@GMAIL.COM
 6. OTHER DETAILS
Occupation Details

Private Sector Government √ Public Sector Self Employed Professional Agriculture

Homemaker Student Others-Retired Other (please specify)

Income Range (per annum) Upto 1 lac 1 lac to 5 lac 5 lac to 10 10 lac to 25 lac 25 lac and above
Educational Qualifications Below SSC SSC HSC Graduate Masters Professionals ( CA, CS, CMA, etc.)

Please Tick If Applicable Politically exposed Related to Politically exposed

7.SUBSCRIBER BANK DETAILS:

Account Type Savings A/c √ Current A/c

Bank A/c Number 35095087108

Bank Name* STATE BANK OF INDIA
Branch Name GAYATRI COMPLEX, SIDHI
Branch Address GAYATRI COMPLEX,NAGARPALIKA BUILDING,BUS STAND ROAD

Pin Code * 486661

State/U.T. MADHYA PRADESH

Country INDIA
Bank MICR IFS Code SBIN0030380

8. SUBSCRIBER NOMINATION DETAILS*

Name of the Nominee (You can nominate up to a maximum of 3 nominees and if you desire so please fill in Annexure III (Additional Nomination Form)
provided separately)

Name of the Nominee provided

Nominee Name PREMLAL GUPTA

Relationship with the Nominee FATHER

Date of Birth (In case of Minor)

Nominee’s Guardian Details (in case of a minor)

Nominee’s Guardian

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

I would like to subscribe for Tier II Account also YES NO If yes, please submit details in Annexure I.
√
10. PENSION FUND (PF) SELECTION AND INVESTMENT OPTION*
(i) PENSION FUND SELECTION (Tier I): Please read below conditions before opting for the choice of Pension Funds:

(a) All Citizen Model: Subscribers under All Citizen model has the option to choose one of the available PFs as per their choice in the table below.
(b) Corporate Model: Subscribers shall have the option to choose one of the available PFs as per the below table in consulation with their respective Employer.

(c) Government Sector:For Government Subscribers, the following PFs act as default PFs as per the guidelines issued by the Government
(a) LIC Pension Fund Limited (b) SBI Pension Funds Pvt. Limited (c) UTI Retirement Solutions Ltd.
Name of the Pension Fund PFM Selected

LIC Pension Fund Limited

SBI Pension Funds Private Limited

UTI Retirement Solutions Limited

ICICI Prudential Pension Funds Management Company Limited

Kotak Mahindra Pension Fund Limited

Reliance Capital Pension Fund Limited

HDFC Pension Management Company Limited

BIRLA Sun Life Pension Management Limited

* Selection of Pension Fund is mandatory both in Active and Auto Choice. In case, you do not indicate a choice of PF, please note that it is deemed that you have
consented for the default PF specified by PFRDA. Currently, SBI Pension Funds Private Limited is the default PF.

(ii) INVESTMENT OPTION (Available for All Citizen Model and Corporate Model Subscribers)
Active Choice Auto Choice
For details on Auto Choice, please refer to the Offer Document. Please note:
1. In case you select Active Choice fill up section III below and if you select Auto Choice fill up section IV below.
2.In case you do not indicate any investment option, your funds will be invested in Auto Choice (LC 50).
3. In case you have opted for Auto Choice and fill up section III below relating to Asset Allocation,
the Asset Allocation instructions will be ignored and investment will be made as per Auto Choice.
 (iii)ASSET
(iii) Asset Allocation
ALLOCATION (to be filled up only in case you have selected the 'Active Choice' investment option)

Asset Class E C G A Total

(Cannot exceed 50%) (Max up to 100%) (Max up to 100%) (Max up to 100%)

% share 100%

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.

(iv) 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

LC 75 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
LC 50 3. LC 25- It is the Life cycle fund where the Cap to Equity investments is 25% of the total asset

LC 25

11. DECLARATION BY SUBSCRIBER*

Declaration & Authorization by all subscribers

√ I have read and understood the terms and conditions of the National Pension System and hereby agree to the same along with the PFRDA Act, regulations
framed there under and declare that the information and documents furnished by me are true and correct, to the best of my knowledge and belief. I undertake
to inform immediately the Central Record Keeping Agency/National Pension System Trust, of any change in the above information furnished by me. I do not
hold any pre-existing account under NPS. I understand that I shall be fully liable for submission of any false or incorrect information or documents.

√ 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 website and view details) & T-PIN.

√ I agree to take a printout of the registration form from CRA portal, paste photograph, affix signature and send it to CRA. I understand that my PRAN will be
‘frozen’ temporarily if the form is not sent to CRA within 90 days from the date of allotment of PRAN. (Applicable only for Aadhaar based Subscriber
Registration).
√ I understand that my initial contribution will be credited in my PRAN but I will not be able to make any further contribution till the KYC compliance is confirmed
by the Bank selected by me during registration. Once the KYC compliance is confirmed by Bank, I agree to take a printout of the registration form from CRA
portal, paste photograph, affix signature and send it to CRA. I understand that my PRAN will be ‘frozen’ temporarily if the form is not sent to CRA within 90
days from the date of allotment of PRAN. (Applicable to Subscribers registering with PAN and subsequent KYC verification by Bank).

√ I hereby declare that I am the bonafide subscriber of NPS and the contribution being paid for this transaction pertains to my PRAN. I further declare that
I will make payment from my bank account.

Declaration under the Prevention of Money Laundering Act, 2002

√ I hereby declare that the contribution paid by me has been derived from my 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.

Date 1 3 / 0 5 / 2 0 1 9

Place :

Signature/Thumb Impression* of Subscriber in black ink

(* LTI in case of male and RTI in case of female)
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
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 1 3 / 0 5 / 2 0 1 9

Place :

Signature/Thumb Impression* of Subscriber in black ink

First Name * ANUJ KUMAR GUPTA (* LTI in case of male and RTI in case of female)
13. DECLARATION BY EMPLOYER

Applicable to Government Subscribers only

(Subscribers Employment Details to be filled and attested by the Deptt. (All Details are Mandatory)

Date of Joining 08/03/2019 Date of Retirement 30/04/2057

Employee Code/ID (If applicable)

PPAN (If applicable)

Group of Employee (Tick as applicable) Group A Group B Group C √ Group D

Office NAGAR PARISHAD, BUDHAR

Department UADD
Ministry UAD
DDO Registration Number SGV146910D

DTO/PAO/CDDO/DTA/PrAO Registration Number 4014474

Basic Pay 19500
Pay Scale 5200 20200 1900

It is certified that the details provided in this subscriber registration form by ANUJ KUMAR GUPTA
employed with us, including the address and employment details provided above are as per the service record of the employee maintained by us. Also, it is further
certified 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 Authorised person Rubber Stamp of the
(In the box above) DTO/PAO/CDDO/
(In the box above) (In the box above)

Designation of the Authorised Designation of the Authorised

Name of the DDO Name of DTO/PAO/CDDO/DTA/PrAO

Deptt/Ministry Date
14. TO BE FILLED BY POP-SP
Receipt No. (17 digits) 2000677501

POP-SP Registration Number NULL

KYC Compliance Yes No

Document accepted for date of Birth Proof

Copy of PAN card submitted Yes No

Document Received: (Originals Verified) Self Certified (Attested) True Copies:

Identity Verification: Done

Existing Bank Customer:

I/we hereby certify/confirm that Shri/Smt/Kum …………….............is an existing customer of the Bank having fully operative Saving Bank account
no…………………..at…………..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 S. B. a/c of Sh/Smt/Kum……………is not a ‘Basic Savings Bank Deposit Account’ .

Adhaar Based KYC Certificate:

I/we hereby certify that Aadhaar Number ………………………...of Sh/Smt/Kum…………………………………….......has been checked and the name and address
mentioned on the original Aadhaar card are matching with that mentioned on NPS application form.

To be filled by POP-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 110113616923

ACKNOWLEDGEMENT
Name of the Subscriber: ANUJ KUMAR GUPTA

Contribution Amount Remitted:

Date

Stamp and Signature of the Employer/PoP: