ATAL PENSION YOJANA (APY)

(Administered by Pension Fund Regulatory and Development Authority)

SUBSCRIBER REGISTRATION FORM

To The Branch Manager/Officer In Charge, Branch, Bank/Dept. of Post

Dear Sir/Madam,
I hereby request that an APY account be opened in my name under National Pension System (NPS) as per the particulars given below:
* Indicates mandatory fields. Please fill the form in English and BLOCK letters
1. BANK DETAILS:
Bank A/c Number*
Bank Name* Bank Branch*

2. PERSONAL DETAILS:
Name of Applicant in full* Shri Smt. Kumari
Full Name*
Date of Birth* d d / m m / y y y y Age Mobile No
Email ID Aadhaar*
Married Yes No If married , spouse name is mandatory. Spouse will be the default nominee under APY.
Name of Spouse Aadhaar
Nominee’s Name* Aadhaar
Nominee’s relationship with the subscriber
Additional Details in case nominee is a Minor
Date of Birth* d d / m m / y y y y
Guardian’s Name*
Whether beneficiary of other statutory social security schemes Yes No
Whether Income Tax Payer Yes No
Is FATCA/CRS* applicable $ Yes No
$ FATCA/CRS is applicable for US Persons/Tax Residents other than India. FATCA/CRS Declaration Form needs to be submitted if you are an US person or your Country of
Birth / Country of Citizenship / Country of Residence for Tax Purpose is a country other than India.

3. PENSION DETAILS

Frequency of Contribution (Please tick(√)) * Monthly   Quarterly   Half Yearly  

Pension Amount (Please tick(√)) * 1000 2000 3000 4000 5000
Contribution Amount I hereby authorize the bank to debit my above mentioned bank account till the age of 60 for making
payment under APY as applicable based on my age and the Pension Amount selected by me. If
(in Rs.)
the transaction is delayed or not effected at all for insufficient balance, I would not hold the bank
(To be filled by the Bank) responsible. I also undertake to deposit the additional amount together with overdue interest thereon.

Declaration & Authorization by all subscribers

I meet the prescribed eligibility criteria for assistance under APY and I have read and understood the terms and conditions of the Scheme. I hereby agree to the same and
declare that the information furnished by me is true and correct, to the best of my knowledge and belief. I undertake to immediately inform the bank of any change in the above
information furnished by me. Further, I do not hold any pre-existing account under APY. I understand that I shall be fully liable for submission of any false or incorrect information
or documents. I have read/been explained and have understood the APY guidelines. I further agree to be bound by the terms and conditions of provision of services under the
scheme as approved by PFRDA/Govt. of India.
I hereby authorize PFRDA to use my Aadhaar details for APY 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 and Services) Act, 2016 and rules and regulations notified thereunder. I have been given to understand that
my information submitted to PFRDA herewith shall not be used for any other purpose other than mentioned above, or as per requirement of law.

Date d d / m m / y y y y
Signature/Thumb Impression* of Subscriber
Place (* LTI in case of male and RTI in case of female)

ACKNOWLEDGEMENT - SUBSCRIBER REGISTRATION FOR ATAL PENSION YOJANA (APY)

(To be filled by the Bank)
Name of the Subscriber:
PRAN Number
Guaranteed Pension Amount Periodicity of Contribution
Contribution Amount under APY (in Rs.)

Name of the Bank:

Bank Branch:
Receiving Officer’s Name:
Date of Receipt of Application: Stamp and Signature of the Bank

*Atal Pension Yojana has now been included under the Section 7 of the Aadhaar (Targeted Delivery of Financial and Other Subsidies, Benefits and Services) Act 2016. As per the
provisions of the act, any individual who is eligible to receive benefits under the scheme will have to furnish proof of possession of Aadhaar number or undergo enrolment under
Aadhaar authentication. All new APY registrations will have to comply with the above directives.
 ATAL PENSION YOJANA (APY)
(Administered by Pension Fund Regulatory and Development Authority)
SUBSCRIBER REGISTRATION FORM

To The Branch Manager/Officer In Charge, Branch, Bank/Dept. of Post

Dear Sir/Madam,
I hereby request that an APY account be opened in my name under National Pension System (NPS) as per the particulars given below:
* Indicates mandatory fields. Please fill the form in English and BLOCK letters
1. BANK DETAILS:
Bank A/c Number*
Bank Name* Bank Branch*

2. PERSONAL DETAILS:
Name of Applicant in full* Shri Smt. Kumari
Full Name*
Date of Birth* d d / m m / y y y y Age Mobile No
Email ID Aadhaar*
Married Yes No If married , spouse name is mandatory. Spouse will be the default nominee under APY.
Name of Spouse Aadhaar
Nominee’s Name* Aadhaar
Nominee’s relationship with the subscriber
Additional Details in case nominee is a Minor
Date of Birth* d d / m m / y y y y
Guardian’s Name*
Whether beneficiary of other statutory social security schemes Yes No
Whether Income Tax Payer Yes No
Is FATCA/CRS* applicable $ Yes No
$ FATCA/CRS is applicable for US Persons/Tax Residents other than India. FATCA/CRS Declaration Form needs to be submitted if you are an US person or your Country of
Birth / Country of Citizenship / Country of Residence for Tax Purpose is a country other than India.

3. PENSION DETAILS

Frequency of Contribution (Please tick(√)) * Monthly   Quarterly   Half Yearly  

Pension Amount (Please tick(√)) * 1000 2000 3000 4000 5000
Contribution Amount I hereby authorize the bank to debit my above mentioned bank account till the age of 60 for making
payment under APY as applicable based on my age and the Pension Amount selected by me. If
(in Rs.)
the transaction is delayed or not effected at all for insufficient balance, I would not hold the bank
(To be filled by the Bank) responsible. I also undertake to deposit the additional amount together with overdue interest thereon.

Declaration & Authorization by all subscribers

I meet the prescribed eligibility criteria for assistance under APY and I have read and understood the terms and conditions of the Scheme. I hereby agree to the same and
declare that the information furnished by me is true and correct, to the best of my knowledge and belief. I undertake to immediately inform the bank of any change in the above
information furnished by me. Further, I do not hold any pre-existing account under APY. I understand that I shall be fully liable for submission of any false or incorrect information
or documents. I have read/been explained and have understood the APY guidelines. I further agree to be bound by the terms and conditions of provision of services under the
scheme as approved by PFRDA/Govt. of India.
I hereby authorize PFRDA to use my Aadhaar details for APY 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 and Services) Act, 2016 and rules and regulations notified thereunder. I have been given to understand that
my information submitted to PFRDA herewith shall not be used for any other purpose other than mentioned above, or as per requirement of law.

Date d d / m m / y y y y
Signature/Thumb Impression* of Subscriber
Place (* LTI in case of male and RTI in case of female)

ACKNOWLEDGEMENT - SUBSCRIBER REGISTRATION FOR ATAL PENSION YOJANA (APY)

(To be filled by the Bank)
Name of the Subscriber:
PRAN Number
Guaranteed Pension Amount Periodicity of Contribution
Contribution Amount under APY (in Rs.)

Name of the Bank:

Bank Branch:
Receiving Officer’s Name:
Date of Receipt of Application: Stamp and Signature of the Bank

*Atal Pension Yojana has now been included under the Section 7 of the Aadhaar (Targeted Delivery of Financial and Other Subsidies, Benefits and Services) Act 2016. As per the
provisions of the act, any individual who is eligible to receive benefits under the scheme will have to furnish proof of possession of Aadhaar number or undergo enrolment under
Aadhaar authentication. All new APY registrations will have to comply with the above directives.
 APPLICATION FOR LINKING/ SEEDING AADHAR NUMBER
AND RECEIVING DBT BENEFITS INTO BANK ACCOUNT-(NPCI MAPPING)*

The Branch Manager, Date:

……………………….Branch
……………………….Bank
Dear Sir,
Account No. _________________ in A/c Name _______________
Linking / Seeding of Aadhaar in NPCI-Mapping for Receiving Direct Benefits

I am maintaining a Bank account No. ______________ with your Branch.

2. I submit my Aadhaar number and voluntarily give my consent

to: o Use my Aadhaar Details to authenticate me from UIDAI.
o Use my Mobile Number mentioned below for sending SMS Alerts to me.
o Link the Aadhaar Number to all my existing/new/future accounts and customer profile (CIF) with your Bank.

(Signature/Thumb Impression of customer)

OPTION FOR RECEIVING DBT BENEFITS ( TICK ONE)

o I wish to seed my account No. _______________ with NPCI mapper to enable me to receive Direct Benefit
Transfer (DBT) including LPG Subsidy from Govt. of India (GOI) in my above account. I understand that if
more than one Benefit transfer is due to me, I will receive all the benefit transfers in the same account.(for
customer who have not so far seeded account with NPCI Mapper)
o I already have an account with ________________ (name of Bank) having IIN Number**__________, and
seeded with NPCI Mapper for receiving DBT from GOI. I request you to change my NPCI mapping(DBT
Benefit Account) to my account with your Bank.
o I already have an account with another bank ________________(name of Bank) having IIN
Number**__________, and seeded with NPCI Mapper for receiving DBT from GOI. I do not want to
change my NPCI mapping(DBT Benefit Account) from the existing Bank.
o I do not wish to seed my accounts from your Bank with NPCI Mapper (I will not be getting DBT).

3. I have been explained about the nature of information that may be shared upon authentication. I have been given to
understand that my information submitted to the bank herewith shall not be used for any purpose other than
mentioned above, or as per requirements of law.

4. I hereby declare that all the above information voluntarily furnished by me is true, correct and complete.

Yours faithfully
[if consent sent through BC/BDO/VO]

(Signature/Thumb Impression of customer) o I hereby authorise the Banking Correspondent

……………………………………...
o I hereby authorise the Sarpanch,/ V.O./B.D.O./
Name : .……………………………………….…
to submit the above consent letter to the bank.
Mobile No.:

Email:

Encl: Copy of Aadhaar

(Signature/Thumb Impression of Customer)

*NPCI Mapping : Mapping is a process of associating a Bank with Aadhaar number which is facilitated by NPCI
for Direct Benefit Transfer to the respective Bank who have linked the Aadhaar Number to a specific Bank account
for receiving Direct Benefits to which customer has given the consent.
** IIN number will be provided by Bank receiving the consent Application
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