-r[z ATAL PENSION YOJANA

rhe rdministered Pension Fund and

SUB$CRIBER REGISTRATION FORM
Deve iuthor

To The Branch Manager/Olfcor ln Ch6rge, Branch Bank/Dept. of Post

Dear Sir/Madam.
I hereby requesl that anAPY accounl be opened in my name under Nal@nal Pensiofl System (NPS) as per the particulars gMen betow
'lndicates mandatory faelds- Please fillthe form in English and BLOCK letters
1. BANK DETAILS
Bank A,/c Numbor'

Bank Name'
r_i I l
Bank Branch'

2. PERSONAL
'TTAILS
Name of Applicant in full' sh smr. E Kumari fl
Fu lName' =
Dale of Birth' tl Age __ j Mobile No
EmarllD Aedhaaa
Married Yes- No lf married, spouse name is mandatory. Spouse willb€ the default nominee underAPY
Name of Spouse
-
Nominee s Name' ] naataar i

Nomrnee s relalronshrp wrll the sLbscflber

Additional Delai13 in caae nominee is a Minor
Date of B,rth' I I
Guardian's Name'
\ruhether beneficiary of other statutory social security schemes Yes NoI i
Whether Income Tax Payer Yes Noll
ls FAICAJCRS' applcable S ye6 E No-
S FATCNCRS is applicable lor US PeBondTax Residents othet than lnclia. FATCA/CRS Dechralion Fom neecls ta be subnifled rt you arc an US person ot your Countty of
Bi.th / Couotty ol Citizenship / Country ol Residence fot Ta\ Putpose is a country othet than lnelia.

Fr6qu6ncy ofContribution (Pl6.s6 trck(l)) ' Monthly Ouanerly L l Hall Yearly :

PensionAmount (Please tick(9)' IOOO uooo f 3ooo I 4ooo E 5000

Contribution Amouot = I nereby authori2e the bank lo debil my above menlioned nanl accounl lilllhe age of 60 for making
payment underAPY as applieble based on my age and lhe Penson Amount selected by me f
(io Rs.)
lh€ irans.clion is del.yed or not ellecied at all lor inattfcient balance I wolld not hold the bank
(To be nlled by tho aank) rcsponsible lalso undenaketo deposil lhe addilional amounttogelherwilh overdue interesliherefl.

D6claration & Authorization by all subscritle€

I meet lhe prescribed eliqibility crleria for assistance underAPY and I have read and understood lhe terms and condilions of lhe Scheme. I hereby aoree lo lhe same and
doctare thst the informaiion tuhished by me is true and corect, !o lho bosi of my knowledge and belief. I underl€k6lo immediately intorm lhe bank ofany change in the above

or documenis. I lrave read/been explaned and have underslood iheAPY guidelines lturlher agrce lo be bound by lhe terms and condilions of Provision ol services under ihe
scheme as approved by PFRDI,/Go!,I of lndia.
I hereby aurhorize PFRDA to use my Aadhaar delails for APY and althenticate my idenlily lhrough lhe Aadhaaraulhenlication syslem in accord6nce with the provisions o{ the

my rnlormarion submi(ed ro PFRDA herewitr shallnot be used fo. any other purpose other Ulan meniioned above. oras per rcqutemenl of law

Oate Signature/Thumb lmpression' of Sub6criber

Place
(' LTI in case of male and RTI in case of female)

ACKNOWLEDGEMENT - SUBSCRIBER REGISTRATION FOR ATAL P PY)

(To be filled by the Bank)
Name of the Subscriber

PRAN Number

Guaranleed Pension Amounl Periodicity of Conlribution

Cont.ibution Amount underAPY (in Rs

Name of the Bank
Bank Branch
Receiving Otficer's Name:
Date of Receipt ofApplicalion Stamp and Signature of the Bank

.Aret pen sron yo a na has now been rnctuded nder lhe Sertion 7 ol lhe Aadhaar ( Targeled Oehvery ol F inano8 ald Olher Subsidie s Benefts ard SeNrces, Acl 2016 As per lhe
L
;;;;;;i]i;';ai ;;, i;;, o,ii.t to ,eie,ve benenrs urder tr'e 3cheine wirr have ro turnrsh proor or oossess'on oI Aadhaar number or undarso enrohent undd
Jis ir'o'oti
Aaiinii, i,rtlntc-at"" Allnew APY es,srral,6rs Mllhave ro @mprv wdh ihe above dtreclrves