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Request For Change/Correction in Subscriber Master details And/OrReissue of I-Pin/T-Pin/PRAN

For POP-SP
Date of Receipt: POP-SP Registration No. :

Receipt No.:

Entered By : 110135265739 Date: 18/10/2023

Verified By: Date:

PRAN is mandatory. Fill only the field(s) which is/are to be modified with the revised details.
I hereby request for the following details for the change. (Please tick )
I) Change or Correction in name II) Changes or Correction in other Personal

III) Changes or Correction in Nomination √ IV) Reissue of I PIN and/or T PIN

V) Reissue of PRAN Card

Permanent Retirement Account Number *: 110135265739

Section A – Change in Personal Details

1. Full Name (Full expanded name: Initials are not permitted)

Please Tick as applicable Shri Smt Kumari

First Name *

Middle Name

Last Name

If the correction in the name to be made in Hindi, Yes

2. Gender Male Female

3. Date of Birth

4. PAN

5. Category: Government Private Self Employed NRI Others

6. Fathers Full Name:

First Name *

Middle Name

Last Name

7. Present Address*
Flat/Unit No, Block no.

Name of Premise/Building/Village

Road/Street/Lane

Landmark

District/Town/City

State / Union Territory

Country

Pin

8. Permanent Address*: If same as above, Please Tick else

Form submitted using OTP
Flat/Unit No, Block no. Authentication (through Email and
Mobile)
18-10-2023 10:34:53
Name of Premise/Building/Village

Road/Street/Lane

Landmark

District/Town/City

State / Union Territory

Country

Pin Code
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9. Phone No.

10. Mobile No.

11. Email ID

12. Do you want to subscribe to SMS Alerts (To be made available later, on a Yes No

13. Subscribers Bank Details:

You want to change Bank details of: Tier I Tier II Tier II Tax Saver

Tier I Account : Savings Current

Bank A/c Number

Bank Name

Bank Branch

Bank Address

Pin Code

Bank MICR Code

IFS code (Wherever applicable)

Tier II/Tier II Tax Saver Account: If same as above for Tier I Yes else,
Savings A/c Current A/c
Bank A/c Number

Bank Name

Bank Branch

Bank Address

Pin Code

Bank MICR Code

IFS code (Wherever applicable)

√ Section B - Subscriber’s Nomination Details

You want to change Nomination details Tier I √ Tier II Tier II Tax Saver

Tier I Account :
1. Name of the Nominee:

1st Nominee 2nd Nominee 3rd Nominee

First Name First Name First Name

VIDHYA

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

SUGUMAR

2. Date of Birth* (Only in case of a minor):

1st Nominee 12/04/1997 2nd Nominee 3rd Nominee

3.Nominee Age * :

1st Nominee 26 2nd Nominee 3rd Nominee

4. Relationship with the Nominee:

1st Nominee 2nd Nominee 3rd Nominee

OTHER

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5. Percentage Share:

1st Nominee 100 % 2nd Nominee % 3rd Nominee %

6. Nominee’s Guardian Details (Only in case of a minor):

1st Nominee 2nd Nominee 3rd Nominee

First Name First Name First Name

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

√
I understand and consent to that nomination being made by me now shall be invalid ab initio if it is not consistent with Regulation 32
of PFRDA (Exit and Withdrawals) Regulations, 2015 and amendments

Tier II/Tier II Tax Saver Account : If same as above for Tier Yes else,

1. Name of the Nominee:

1st Nominee 2nd Nominee 3rd Nominee

First Name First Name First Name

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

2. Date of Birth* (Only in case of a minor):

1st Nominee 2nd Nominee 3rd Nominee

4. Relationship with the Nominee:

1st Nominee 2nd Nominee 3rd Nominee

5. Percentage Share:

1st Nominee % 2nd Nominee % 3rd Nominee %

6. Nominee’s Guardian Details (Only in case of a minor):

1st Nominee 2nd Nominee 3rd Nominee

First Name First Name First Name

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

I understand and consent to that nomination being made by me now shall be invalid ab initio if it is not consistent with Regulation 32
of PFRDA (Exit and Withdrawals) Regulations, 2015 and amendments

Section C –Request for Reissue of I-PIN/T-PIN

I hereby request you to reissue the following

T-PIN I-PIN
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Section D –Request for Reissue of PRAN card.

Reissue of T-Pin, I-Pin and reissue of PRAN card will be chargeable by the CRA.

I , the applicant, do hereby declare that the information provided

above is true to the best of my knowledge & belief.

Date
Signature/Thumb
Impression* of the Subscriber

To be filled by POP-SP
KYC Compliance (Section A – 1,2,3, 7, & 8) : Yes

KYC document accepted for identify proof :

KYC document accepted for address proof :

Document accepted for date of birth proof :

Copy of PAN card submitted : Yes No

PAN Compliance : Yes

Signature of Authorized Signatory

Name : Place :

Designation : Date :
POP-SP Seal

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

Received by: CRA-FC Registration

Received at: Date:

Acknowledgement Number
(To be provided by CRA-FC)