Annexure N5 NPS-Lite CONTRIBUTION SUBMISSION FORM [Under New Pension System (NPS)] Transaction ID Number (Given by NPS-Lite) NL-AO/NL-OO Reg. No. 8000123 NL-AO/NL-OO NAME(Department/Office) SAHASTRADHARA KSHETRIYA GRAMIN SERVICES NL-AO/NL-OO Address Flat/Unit No. Block No. 38 A Name of Premise/Building/Village JOGIYANA POST OFFICE ATHURWALA Area/Locality/Talukka NEAR JOLLY GRANT AIRPORT District/Town/City DEHRADUN State / Union Territory Uttaranchal Country India Pin Code 248144 Phone Number 01352412724 FOR USE IN RECEIVING BANK Total Contribution Subscriber Contribution Co-Contribution Total Total in words Amount (in Rs. only) 4500.00 0.00 4500.00 Four Thousand Five Hundred Rupees only TENS Dated UNITS Cash / Debit to A/c / Cheque Credited on 1500012800049



DETAILS OF PAYMENT (To be filled by NL-AO/NL-OO) CRORES LACS THOUSANDS HUNDREDS Paid in Cash/Debit to A/c/Cheque No. Drawn On (Name of the Bank & Branch) Date:


(Signature of person making payment) Rs. NL-AOs/NL-OOs Counterfoil NL-AO/NL-OO Reg. No. On Account of Pension Fund Contribution Received from (NL-AO/NL-OO Name) Cash/Debit to A/c/Cheque No. For Rs. (To be filled up by NLAO/NL-OO ) Rs.(In Words) Four Thousand Five Hundred Rupees only Drawn On (Name of the Bank & Branch) Rs. This Transaction ID is given by NPS-Lite after submission of Subscribers' Contribution file. Cheques/DDs should be drawn in favour of Bank of India - NPS Trust Account - A/c Number 012210111111111 In case of Electronic Fund Transfer PAOFIN80001231500012800049 should be written in Field 7495 (Sender to receiver information, line No.4) of RTGS Message or in Field 7002 (Origination of remittance) of NEFT Message 8000123 SAHASTRADHARA KSHETRIYA GRAMIN SERVICES Transaction ID Number (Given by NPS-Lite) 1500012800049 SPACE FOR BANK SEAL

4500.00 Status-SubscriberContribution&batchId=80001230000000000009[3/11/2011 10:54:12 AM] Status-SubscriberContribution&batchId=80001230000000000009[3/11/2011 10:54:12 AM] .ntrChallan.NPS-Lite NL-AO/NL-OO to send RTGS remittance by R-41 RTGS format only

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