Wer Annexure - S2 NATIONAL PENSION SYSTEM (NPS) Central Recordkeeping Agency (CRA) -Protean eGov Technologies Limited. (formerly NSDL e-Governance Infrastructure Lt.) Request For Change/Correction in Subscriber Master Details And/Or Reissue of -PIN/T-PIN/PRAN Card (To aod mitts) lease read accompanying stuns careful before ting w efor] | | [For PoP-SP/DDOML-CC use: Registration No Date of Receipt /PAOIDTOIDTA/PrAOI NL-AOINL-OO use: POPIPOP-SP/PAO/DTOIDTAPrAOINL-AO! NLO Stamp: | Stonaure ano Stamp of POP-SPrODOML.Co Date: Date Receipt No. (Manda for PORPOR SP) ‘Acknowedigerent No, (Toe fied by Nol eas generate by NPSCAN/CRA spt) "hereby request fr he folowing details forthe change Please tek (7) ‘A) Change or Correction in Subscriber Master Details 8) Reissue of KIN or PIN mot Aopca or NPS Li Sts) C) Reissue of PRAN Card Permanent Retirement Account Number hereby et the folowing dell f change flare ek () the Boron eft margin of appropiate row where changucorecton i round and prove he dts ne cerresponding rows Section A ~ Change of Correction in Subscriber Mastor Detals(* indicates Mendatoy Fei) [WA PERSONAL DETAILS: Pear rterio Si Not cine mabucion) Name of Applicat in fu Shi Sm Kumar FirstName P URUSH OTHAMAN Middle Name NASR LastName yy Suter’ Maiden Name Father's Ful Name: FirstName Middle Name LastName Mother's Full Name: First Name Middle Name Last Name Date of Bith 1 ' (Bate f Btn shoud be suport by relevant documertary poo, Nod Oce shal very hae ble updating detain he GRA stem) Gender please ick ¢)] Male Female Others Martal Status [please ck (¥)] Married Unmarried Others PAN CARD ‘Spouse Name Ss (Rte S ta anetn) KYC Number rato Catal YF Sibsin et ply sae ny Retreent Aver Cade KY Number, Retirement Adviser Code and Spouse Name olds are not applicsbefor Goverment & NPS Lite Subscribers ‘2. PROOF OF IDENTITY (Pol) (ry one oF ne documents need io be proved along wh he ieifcaon rare) Pave eS No 2 mar) Passport Passport Expiry Date 1 , Voter 1D Card PAN Card Driving License Driving License Exply Date NREGA JOB Card others "Name ofthe 10 Pena SNe. 2. cone UID (Aadhaar) [Jove arene To6Vout Annexure - S2 a a imereneheome ee ea Smee ———————— ————— ROE ARE Tr Atwater] Rear] be) Reet ata ‘tere ima peiebangne armani sto coroner oma [42 PERMANENT ADDRESS DETAILS) [ik v)intheboxincaethe adress area above J (ee era 2 en) ‘Adecess Typet ResicontaiBusiness Residensal Business Registered Ofice Unspecified FatRoom/Doefaoc ro, Landmark PremisesuldngNiage RoadSSveetLane ‘Areal. ocalty Talk CtyrTounistiet ‘State W& CONTACT DETAILS Tomine) + Wf sn) + Mote + 81949659 54.07 Mote Nunberisregsns tr communton ant ost SMS ses) mato Mv PNAIRT2Z541@9@GMATL-Com [Cs OTHER DETAILS (esse alorts ro, 3 ofthe natuctons) > Occupation Deals { pease tek) ] Private Secor |_| Public Secor |) Government Sector | Potessonal Set Emeloyed Homemaker ‘Suent ‘thers (Pease Sei) > Income Range (per annum) Upto lac tlsta Sie Slacto 10lac | 10lacto25iae | 25iac and above > Eavcabonal Qualistions Seow SSC [SSCL] HSC Graduate | Masters Prolesseals (CA, C5, CMA, ee) > Please Tikit Alcale _Palicaly exposed person Related to Polticaly exposed Person _| Please refer instruction na.3) [5277 SUBSCRIBER BANK DETAILS {Al bank deta are mandatory except MICR Gade. (Pas rie So. 4 hen) You wanttochange Bank details fer Ter (incase yu want to change bank details n bath Tiel & Tle il Account ek bath heck bx) Tier Account : savings Ale Curent Ae BarkAletumbr 4 OF TOITIIO3 Benk Name STATE BANK OF INDIA BnchNeme = PAY ANNUR APB Branchaderess CITY MALL Govt. HOSPITAL READ Pincwe b 7° 207 Dist. KANNUR: KERALA: THDrA- BankMR Cade GTR OORIGZ sce SRrNeSookLSl Tier il Account: 1 same a Ter, Please Tick (ese, provide the datas below: Savngs Ale Curent Ale Bank Ate Number Bank Name Branch Name Branch Adéress Bank MICR Code ToreVer Lt Annexure - S2 “8. SUBSCRIBERS NOMINATION DETAILS (Pease eer lo Sc No. Sete tons) ‘You want to change Nomination details of: Tier! Ter! (tn.case you want to change nomination detain both Tle | & Ter Account, tek both check box) 1 Account : Name ofthe Nominee (You can nominee up 8 maximum 3 namie an you desks lease in Anal Norinton Form proved on page. 48 sept) First Name ‘Middle Name Last Name Relationship wah the Nominee Date of Bit (in case of Minor) Nominge's Guardian Details (in case ofa minor) First Name ile Name Tier Il Account : it same as Tir |, Please Tick (els, provide the Yotalis below: Name of the Nominee (Youcannominete up & maximum ct 3 nominees ant you dee so ebcAdonal Nomination Ferm provid on pages 4 & 5S speay) First Name Mido W Last Name Relationship wah the Nominee In case of Minor) Nominee's Guardian Details (in case ofa minor) First Name ‘Section B — Request for Reissue of LPINIT-PIN Nx Apptcaie for NsLte Subsea | hereby request you to reissue the folowing TIN LPN ‘Section C — Request for Reissue of PRAN card. Reissue of T-PIN, |-PIN and reissue of PRAN card will be chargeable to Subscriberiemployer by CRA. PRAN Card will be re-printed as, per the preference given at the time of registration under NPS. | Curuspe bana Nai 22. the applicant, de hereby deciare thatthe information provided aboves ue to the best ofmy knowledge & bole. 5 ate 17106 | 2022 meres To be filled by POP/ POP-SP YC Compliance YC document accepted for identity proot YC document accepted for addres proof Copy of PAN card submited Yes PAN Compliance Yes Prace POP POP-SP Sealver. Annexure - S2 ADDITIONAL NOMINATION FORM INSTRUCTIONS FOR FILLING IN THE FORM "The deal of nominees to whom the outstanding pansion wealth ofthe Subscibor payable incase ofthe demise ofthe Subscriber before ene proceeds ‘are withdrawn oe provided hereunder (Ploase refer Instruction no 5) Also, pisase note that case of demise ofthe Subscriber afer opting for deferred ‘withdrawal, ll the outstanding pension wealth present inthe NPS account of he Subscriber shall be withdrawn upon receiving the request and paid to the Rominees as mantoned inthis frm and the same would be treated as ful and ral dscharge ofthe obligation. "hereby submit the Nomination deta for (Please Tck(v)) Ter! Teri ‘account under NPS. (Please Tck on above both the option (i. Tier and Trl) n case you want orelain same nomination fr both account and in case of diferent nomination kindl fil separate Nomination Form) 1 heroby nominate the person(s) mentioned below who ifare member(s) ‘of my family to receive the amount in my PRAN account under National Pension Systom inthe vent of my deat, 4. Name of the Nominee: 1st Nominee ‘2nd Nominee 3rd Nominoe Fist Name Fist Name Fist Name Middle Name Middle Name Middle Name Last Name Last Name Last Name 2. Present Communication address of the nominees: ‘Address of 1st Nominee ‘Address of Ynd Nominee ‘Address of 3rd Nominee ‘3. Date of Birth" (Oniy in case of a minor) ‘xtentee [s1s//Inield [iesoneo [atone ‘.laonaip wi Nominee: tstNomine [ 6. erontage Sar: [nome 1 [nd Nernee 1 [Sa Nomnee * {Now's Ouran Dt (ny css ts ri | {at onine’s Guran Ot and Nomin’s Guarda tae _trd mins Ouran Dt Fist Name [Fit Name FistName | Nae Mie name ie Nae | ai Ltn a | bate is doyot 2 ot ‘Signature! Thumb impression” of the Subscriber ‘Note; Left thumb impression in case of iterate male Subscriber and Right thumb impression In case of iterate female subscriber must be obtained. 4016‘TO BE FILLEDIATTESTED BY POP-SP/DDOINL-CC Rubber Stamp of the POP-SPIDDOINL-CC POP-SPIODDONL-CC Registration Number (Allott by CRA) Date , 1 | | | Cetifed thatthe above declaration and nomination details has been signed ! thumb impressed before me by ShiSmMs. aller ne she have read the entries /enries have been read over to him/her by me and got confirmed by him er. Annexure - S2 ‘Signature of the Authorised Person Designation ofthe Authorised Person POP-SPIDDOINL-CC Offs Name ‘TO BE FILLEDIATTESTED BY POPIPOP-SPIPAOIDTOIDTAIPrAOINL-AOINL-OO Rubber Stamp of the POPIPOP-SP/PACIDTOIDTAPYAOINL-AOINL-OO POPIPOP-SP/PAO/DTO/DTAPYAOINL-AOINL-OO Registration Number (Alioted by CRAY ‘Signature ofthe Authorised Person