"NATIONAL PENSION SYSTEM (NPS) - SUBSCRIBER REGISTRATION FORM Contral Recordkeeping Agency (CRA) -Protean eGov Technologies Limited (formerly NSDL e-Governance infrastructure Let) Cena Govt ray Peseesatyourcassoy | ConaiAoomousseey [=| | eget | Co [Please tick(/)] All Citizen Model Cal ¥ fra Lncone) [| corporate Sector o [Netonal Pension System Trust Dear SeMscam. "ery request n NPS 2ocount be opened my name a or he pata given below a recent phatograph of Sens 28 omstte! Pavopon ae ates mandatary, Pease filth fornn English and BLOCK ltr th Bak nk pen. ss eal glidees abemoa rao) YC Number Retirement Adviser Code and Spouse Name fs are nt appeal or Government & NPS Lite Subseribers YC Number eet nm Teeestd tor Cosi TC Regay Fetrement Avior Code patie) r 1. PERSONAL DETAILS: (Fests ofr: ho.1 of be haistons) Name ofApplcantin fil == Shi] sme) kurnari [1] = See ‘Subscriber's Maiden Name Fay ct [ TT I TTT es Cope} Father's Name* GEEK (rar Nt Won) Mother's Name* EET TT TTT T Lr IT) (lr SN erin) Faber are wile pred on PRAY crt case, neers ame wb preted tea of fhe nae [Please ek (%)) (] (erat aster) Residential Status” Inin Date of CI Tele lela ly] tecdunnas! wespricin initectiaiay aie iver + Creer eee County oF rt | Gender [Please tick (“)] Male [_] Female [) Others [] \Nationality* Indian [) ‘Marital Status* Maried [J Unmarried C) Others ‘Spouse Namet F EETTT Cr [aT Der Te “] 7. PROOF OF WENTTTY (Pal? cue tu sols meds be eve atia wn be HGR TES] Passport rT [Passport Expiry Date T T ] VotorD Card | PAN Card Cot Diving License CI [1 [Driving Licsnsa Expiry Date Z Tot NREGAJOB Card L I Others Name oftiew> [| CIE CEST remrararaeretomea] ID (Race) (UII [Aachaar umber not required) espe wa a ese eae roe an mata orca Seer a RS GD SATS TSF OTTO & oars 3. PROOF OF ADDRESS (PoA)" Correspondence Address _ | Permanent Address. (Please tk), a apteabie] EoD ew Wann xen | Faz eg Leese Vaden Oca {at mee han 2 | Reena ee iatieiTTar [Raye an por TORT et aaa TRAN A | eet PTT Ta ATT 4.1 CORRESPONDENCE ADDRESS DETAILS* 3 ‘Acres Type" ResideniafBusiness [] Res al_[] aisinoss[_] registeres omice[_—) Unspocfed [—] dare FlcRoom/Dooriock no. T Promises/Buling Vilage T Road/StrotLane 1 ‘AvoalLocalty/Taluk Jat CiyTowniDisret PIN Code, StatlUT. ee l J 42 PERMANENT ADDRESS DETAILS" C1 ek (7 bx in ee he areas ie same as above. ‘sero Typ ResientavGusiness (—] Resitental [] fusiess[—] Resltredoftol_—] Uns Premises/Bullding’Vilage = [ TTT fours +t (i ‘AcsalLocalty Taluk 1 a ! FiatRoomDoonBiockne. = [TT TT TT TT TT Landmark |_| a fet TI CysTowDisrict Stato.(li) ACTIVE CHOICE ~ ASSET ALLOCATION (to be filed up only in case you have selected ‘Active Choice’ the Investment option) € © 6 - ‘Ass ieee | (Cant | Wacupio | Macupin| (Carnet | Tota [Ave ces Eauty and relted ineiomerts; Asset css C-Coperfe dt end aed eed 72%)| 1005) | 100%) | een!) Tperumenis;Aase class G ~ Goverment Bonds anf rata Insurers Asset Cas | 7 AAtaatv vesmert Funds ncung maranatha CBS, MS, REIT. iF, Ins Soe 0% ‘choses in a | tncaseer Govt enpioyeosbserber he Active che ot Ase Alsons ta Asst ont eter tile ose G ony | Posse not Uso 50 yeas of ago, he macinum partied Equly veeentle 75% of tho ttl asset ocation From 81 years and above, maxinum permed Equly Investment wil be as perth equity ocaion mate provided in Annexure A The apeing fo eau ‘location wl be cared out as per the mati on deo eh ‘Tho otal aloeaton sears E,C, Gand Aasstclasss must be equal 10 100%. In eat, he allocaon st blank andr doesnot eal 10%, the application shall be rjetes AUTO CHOICE OPTION (to be filled up only in case you have selected the ‘Auto Choice’ investment option) In ease, you do not indicate ‘choice of LC, your funds will be invested as per LC 60. Lie yee (66) | Pease Tick(¥)] Choices in Gov Fund ‘Oni One ctor _| Note: LC 7: Its the Lite cyl fund where tha Capt Egy investment ie 75% of te ol eset ion Notavaleio 2.16 So-tis ete eee fd wher the Capo Equly Investment OM cf he otal asset mt 3.L0 25- tls he Ure cyt fund where the Cap fo uty invests 25% ofthe ttl eset toe0 nat, {Gost mpoyoo can excise Auto Chale of Asset locaton for LC 25 &LC 50 ony 125 41, DECLARATION ON FATCA™ Foreign Account Tax Compliance Act) COMPLIANCE (lose roe lo Sina 7 ofthe nalarat Sot US Person* Yes] No [—] Section II" For the purposes of taxation, lam a resident inthe folowing counts and my Tax dentifteation Number (TIN)funcional equivalent in each country is set fut bolow or have ndcated that a TN/functional equivalent is unavaiable (kindly fl detalis of al counties of tax residence if more than one), Particulars CCounty/counties of ax residency Ar ‘Adgress in the jurisdiction for Tax Tome iaoe: Residence a Line 4 ZiPIPost Code “Tax Identifcation Number (TIN}/Functonal equivalent Number “TIN Functional equivalent Number Issuing County \alcty of documentary evidence provided (Wherever applicable) “ott mat. 4) It shall be my responsstiy to educate myself and to comply at al ines wih al elevant laws relating to reporting under section 2858A ofthe Act read with te Rules 14 to 114H ofthe Income tax Rule, 1962 thereunder and the information provided I the Form ein accordans withthe sforeeal les, ») te Infomation provided by mein the Form, ts supporting Annexures es wel a inthe documentary evidencs are, tot best f my knowledge an bel, tue, ‘correct and complete and hat have not wih any mater formation that may aflect the aseesemonVestogarizaton of the acrount asa Reporabe account ‘crotheris. ©) I pormitiauthrce the NPS Trust o collect, store, communicate and process information relating tothe Account and all transactions therein by the NPS Tht ‘nd any of NPS intermediaries wherever situated incuding sharing, ansfr and disclosure between them and the authoriesin andor utd Indla of any confidential information for compliance wih any law or regulation whether domestcoffoelgn. «) | uneriake the respons o decare and disse within 30 day fom the date of change, any changes tat may take plooe inthe inormation provides in the Form, ts supporing Annexures as well asin the documentary evidence provided by me or any cetilcalion becomas correct and fo provide tresh sol ‘corte alongwith documortary evidence, €@) Valeo agre tat incase of my fluro to dscose ary material fact known to mo, now orl future, the NPS Trust may report to any regulator andor any authority ‘esignaed by the Goverment of Incia (GON [RBUIRDATPFROA forthe purpose or take any other action a¢ may be deemod appropiate by tha NPS Trust the Sofclancy shot ramedid by me within the stipulated pviod 1) Thorby acoopt and cknowledye that ine NPS True hal ave the right and author to cary out investigations om the information avallable in pubic domain for confring tne formaton provided by moto the NPS Trust. 19) | also agree to furnish such information andlor documents as the NPS Trust may requre rom time to tien account of any change in aw ear in nda or ‘abroad inthe subjct mater heh, 1h Fahallindemnty NPS Trust for any ies that may aise othe NPS Trust on account of providing incarect or incomplete iermation. ‘Signature/Thumb Impression* of Subseriber in black ink CLTIin case of male and RT in case of females) | Namo of subseibor [TTT CITT TT I ICONTACT DETAILS ret (om owen sr0 exte}[= T_T] Mobile® (Mandatory) [+191 1 | Email Cort [JT TJ (scbite Numbers require for communication and get SMS alrs) ITTTTTTTTitttrrri ti ttrrttrr er ‘6. OTHER DETAILS (ose ero Sno. othe hstvetens) © Occupation Details [ please tick(y)) Private Sector ["] Public Seotor [_] Government Sector [] Professional o SelfEmpioyed(] Homemaker []. student C1 otters (Pease Specty) = : » Income Range (per annum) Upto tac [] 1 lactoSlac D0 Stecto 10 lac Ordlecto2stacl] 25lacandabove = > Educational Quacalons SeowSSCC] ssc] HSC C] Gradunte Castors C] Professionals (CA, 0S, CMA, tc) > Please Tick ifApplicable Politically exposed person [_] Relatad to Politically exposed Person [] (Please refer instruction no.3) {4 anorwesmesslsT TT TTT TTT] [ 7. SUBSCRIBER BANK DETAILS* ( Foase referto Sr no. 4 of tho instructions ) (At bark cea ao mandy excep MNCR Coco) ‘Account Type [ please tick(¥’) ] Savings Nc [—] Banke Nimber CoE | CeCe Bank Name TATE Eee EEE Branch Name COE Branch Address LI Bonk MIGR Code 8, SUBSCRIBERS NOMINATION DETAILS" (Nominaton detals are mandatory. Pease refer to St. No.5 of the instore) Name ofthe Nemine (You an mints a nin feria ds see li anne I ckrl onion Fem) pe son iz stone T : COOCTTT Terr Relationship wih the Nominee [~~ ‘Midcle Name Tast Name: CVT TT PTT TT tt ] ate ofBith incase ofttnor) [TT ‘Nominee's Guardian Detais (in case ofa minor) First Name ~ Wliddie Name ' _ COE eee ee EC |, NPS OPTION DETAILS (ence tek (V) a8 apse) | would the to subscribe for Tier W Account aso YES [JNO [] IVes, please subenl detals in Annexure L (you whe activate Tr acount suteequrty, yous wom sop aplafon Ammen 10) the ascited Nodal Oto oto POPIPOR.SP your hice. The tot POP POP-S8 rendering ania under NPS ens mac S10 ealale on ORA nate) would ke my PRAN to bo printdinHinat_YES JNO (1 10. PENSION FUND (PF) SELECTION AND INVESTMENT OPTION? [ica efoto Srho 6 ofthe Naeons) (). PENSION FUND SELECTION (Tier: Please read below conditions before opting forthe cholee of Pension Fun 4. Government Sector. The flowing Persion Funds (PFs) wil act ity a8 Gln PF, choice w not enticed by the goverment enployeelsibeciber (a)L1C Pension Fue Limite) S61 Pension Funds Pt Lied () UTI Ratoment Scion isn cate Central Aconomeus Bodes (CA) Se Govern (SG)Staie Autonomous Bodies (SAB) employees, slocson mado undr the sacon wil be ignored, if choke to employees I el nalfeg byte espeeae Se GowtMinaty. 2. AllGlizen tod: Suosebers under All Citzen model hav the epton to chooee the valable PF as per ther choice in he able blow, ‘3. Corporate Model: utszrbere chal have te option fo choos th avalatle PFs a prt below ale ncontaon wih te repent Employ ‘4 NPS Lite: HPS Lt is grcup chico moda wher subscribes ache of PF and testmant option at svasla wth Aggresion eT Fay, ase submit deta on Annexure ia ofthe Penson Fund assert om) [Pease Tek Detau hoin of Pension Fan TG Reson Fund ined TI ee) Matte covemant sc: one ort ee [UTI Retiement Solitons ined ee [C1 Pratl Peso Funds anapoet Company Uneed | J Kotak tind Pension Fund nod cH HOF Penn Uanagonert Copan Lind a Ady Bia Sine Peon Meragonant Linked eS * lion of 01 Panton Fendi mandson lr A Clizen mace (i) IVESTMENT OPTION (Peace Tick (inthe tr pan blow shoving your Investment option), ‘ate Chea [——] autacrace [——] Pleas ate: 4. Incase yousslac:Acve Chole tl up section (below and yu elt ito Chole up eecon (i) blow, 2 Incase you do nent any invest oon, your func wl be inveted in Ato Choe (LC 52). ‘3 Incase you nav oped for Auto Coca and fi up section (i below relating to Asset Alsat, te Astot Acai stutons wl be gnared and invetiment wll be made as er Ato Chic (. 6).12, DECLARATION BY SUBSCRIBER® (Plaosrfert Seon 8 the insbusions) Deciarton & Authorization by all ubseriers {Rave ree! and undortod the tema ar conditions fhe Naor Penson Syston and ore sree to fhe same slong wih the PEROAAG, relatos raed hroundor ‘and dere that th formation and document urished by me are tue and cored tothe bet ef my inowledge and bebe. | unceriate onto inet tre Conta Record Keeping AgeneyNational Pension System Trust. of any change ina above ltrmatin lished by Me 80 nat Mold ary poceng menace eon weet derstand hat sl b fy abe or emission of any fase ar ncrrectifrmalon or documents, ‘uta are to be bound by the tems and condition of provision of serves by CRA, fom tne tone and any amandmant thereat as approved by PFROA wheter ‘lec pari wiht ery new decaraten boing funised by me. shal bo Dour by thet and conn fr te usage LPI (lo acore CRA webate ae ets) TPN Declaration under the Provention of Money Laundering Act, 2002 ‘nraby declare that th contibuton pel by melon my behalf hs been deve orn lagaty declared ard assesead sources oncom. | understand tht NPS Tt hes the rita peso my anc profi share the information, wih cher goverment shores tater agree tht NPS Tat has hei to cove ny RAN ncaa found ian to provisos of ary aw relating o prevention of money lundorng. ove FTE) Place: Signature/Thumb Impression” of Subscriber in black ink (LT1in case of malo and RT In cate of formals) 43, DECLARATION BY EMPLOYER ‘Applicable o Government Subscribers only (Subscribers Employment Detals to be filed and attested by the Dept. (All Details are Mandatory) Date of Joining EDEVEEET) Dato of Retirement ployee Coto ot pial) [ ] pipes Cor ant Pr ae opto ou and PeaN(teppieabiy =] ‘pore, enon ay on. Group of Employee (Tick as applicabl Group 8 [_] Group c Group D [J tics Depart nisey 10 Registaon Number DTOPAOICDDODDTAPAO Rogistaton Nunber Basic Pay (ey LTT [TT Pay Scale (hele eae =| _ Its cet thatthe deta proved inthis subscriber registration form by employed with us, induding ‘he edsress and employment deals provided above are as per the service record ofthe employee malriained by us. Ala, tis tuther certified ht helshe has read eniies/entries have bean read aver to himiher by us and got confirmed by hiniher. [Signature cite ord peer” | Rubber Stop aw 000 ‘Snatus of he Ahoised parson | Rubber Samp of te OTOPAOICDDOT (nthe box above) (inthe box above) (ant box above) DTAPIAO (nthe box above) eaten of be Aud Poin — Design ofthe Authorised Peron [J ane tme000 | [Ne tM OCDOOIINPO | Depuntosty [— ese TSE) {/ARATION BY EMPLOYER! CORPORATE : = Applicable to Corporate Subscribers only. (Subscribers Employent Deas tobe led ad eested by Corporate (Al Detals are Mando) Datel ong CEE batt Ratenert empbyercowt EDT TTT TPT ETT) Comsat Rens Nnow Gro noma vyora [TT ET LTT EEE Ere) 20 ote CRA a Cored thatthe details provided in this subscriber registration form by ‘omployed with us, Induding the ‘employment details provided above areas per the service record ofthe enployes malrained by us Also, Ws further certified that ne / she has read the entries /enrieshave been read over to him / herby us and got confirmed by him/her. ‘Signals ofthe Authorised person (hho box above) Deaignaton orineamorseaParcon [ «id Rubber Stamp ofthe Corporate (Inthe box above)