12/08/2022, 14:58 Pradhan Mantri Shram Yogi Maandhan - (PM-SYM)

श्रम एव रोज़गार मंत्रालय

प्रधानमंत्री श्रम योगी मानधन योजना
Ministry of Labour & Employment

Government of India Pradhan Mantri Shram Yogi Maandhan Yojana
असंगठित कामगारों के लिए पेंशन योजना

APPLICATION-CUM-MANDATE FORM (UIN

512G312V01)

PERSONAL DETAILS

Shram Yogi Pension Account Number : 705449116643 Periodicity of Contribution : Monthly

Name of the Beneficiary (As on Aadhar Card) : Chinmayee Sandhibigraha Date of Birth : 12-06-1986

Age : 36 Gender : Female Category : GEN Marital Status : Married

Name of Spouse : INDRAJIT PANDA Occupation : Other

Name of Nominee : Dipanshu Panda Nominee Relation with Beneficiary : Son

Additional Details
(In case of Minor Nominee
)

Date of Birth : 30-10-2016 Guardian’s Name : Indrajit Panda

I am not member of ESIC/EPFO/NPS or income-tax assessee : No

I am also remitting the Monthly Beneficiary Contribution : INR 160/- For assured monthly pension amount of : INR 3000/-

Declaration & Authorization by Beneficiary's

I fulfil the prescribed eligibility criteria
under
Pradhan Mantri Shram Yogi Maandhan. I have read and understood the
terms and conditions of the scheme. I hereby agree to the same. I
declare that the information furnished by me is true and correct
to
the best of my knowledge and belief.Further I do not hold any
pre-existing account under Pradhan Mantri Shram Yogi
Maandhan. I
understand that I am fully liable for submission of any false or
incorrect information or documents given above. I have read / been
explained and I have understood Pradhan
Mantri Shram Yogi Maandhan
guidelines.
I hereby authorize Ministry of Labour and
Employment/LIC/CSC SPV/ to use My Aadhaar details for Pradhan
Mantri
Shram Yogi Maandhan and authenticate my identity through the
Aadhaar
Authentication System in accordance with the provisions of the
Aadhaar (Targeted Delivery of Financial and Other Subsidies,
benefits & Services) Act 2016 and Rules and
Regulations notified
there under.I have been given to understand that my information
submitted to herewith, shall not be used for any purpose other
than
mentioned above or as per
requirement of law.

Date : 12-08-2022 Signature/Thumb Impression* of subsciber

Place : (*LTI in case of Male/RTI in case of Female)

NOTE BENEFICIARY IS NOT REQUIRE TO PAY ANY ADITIONAL FEE OR CHARGE

FOR ENROLLMENT OTHER THAN FIRST CONTRIBUTION
This is subscription cum computer generated acknowledgement and
does not require signature. Shram Yogi Pension Card received.
जिनकी मेहनत देश का आधार, उनकी पेंशन का सपना साकार

UMRN                                         Date 12-08-2022

 
Tick (✓)
Sponsor Bank
Code 259 Utility Code NACH00000000022197
 CREATE
(✓)  
 MODIFY I/We hereby authorize LIFE
INSURANCE CORPORATION OF
INDIA To debit (tick ✓) SB/CA/CC/SB-NRE/SB-NRO/OTHER
 CANCEL Bank A/C
Number 30365169016

With Bank State Bank Of India IFSC SBIN0000094 or MICR                  

An amount of Rupees One Thousand, Nine Hundred   Twenty Only.   1920/-

Frequency
Monthly

Qtly

H-Yrly

Yrly
As & when presented Debit
Type
Fixed Amount

Maximum Amount

Reference 1 705449116643 Phone No. 8895940645

Reference 2 Email ID chinmayeesandhibigraha@gmail.com
I agree for the debit of mandate
processing charges by the
bank whom I am authorizing to debit my account as per latest schedule of charges
published by the bank.

PERIOD
From 12-08-2022 Signature Primary Account Holder   Signature of Account holder   Signature of Account holder

To                
or
Until Cancelled Chinmayee Sandhibigraha   2 . Name as in bank records   3 . Name as in bank records

This is to confirm
that the declaration
has been carefully read, understood & made by me/us. I am authorising the user
entity/ corporate to
debit my account, based on the instruction as agreed
and signed by me. I have
understood that I am
authorized to cancel/amend this mandate by appropriately communicationg the
cancellation/ amendment
request to the User entity/corporate or
the bank where I have authorized the
debit.

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