NATIONAL PENSION SYSTEM (NPS)

eNPS Form
SUBSCRIBER REGISTRATION FORM (All Citizen Model)
√ Aadhaar based registration

Non Aadhaar based registration

Affix recent colour
photograph of 3.5
To,
cm X 2.5 cm size
National Pension System Trust.
Dear Sir/Madam,
I hereby submit my eNPS subscriber registration form

* indicates mandatory fields.

1. PERSONAL DETAILS:
Name of Applicant in full Shri √ Smt Kumari

First Name * R A T A N P R A S A D G U P T A
Middle Name

Last Name

Date of Birth * 0 8 / 1 1 / 1 9 7 9

Gender * √ Male Female Others

Father's Name* S A R V E N D R A P R A S A D G U P T A

2. IDENTITY DETAILS*

PAN A I A P G 0 5 8 3 G Aadhaar 4 9 8 9 1 1 1 7 3 6 8 8 Voter ID

Passport Others

3. CORRESPONDENCE ADDRESS DETAILS*

Flat/Room/Door/Block no. #G-01,711-714

Landmark HARIHARA ENCLAVE

Premises/Building/Village 1ST MAIN 15TH CROSS

Road/Street/Lane

Area/Locality/Taluka HSR LAYOUT SECTOR 6

City/Town/District BANGALORE SOUTH,BANGALORE SOUTH,BENGALURU PIN Code 560102
State/U.T. KARNATAKA
Country INDIA

4. PERMANENT ADDRESS DETAILS: √ Tick ( √ ) in the box in case the address is same as above.
Flat/Room/Door/Block no. #G-01,711-714

Landmark HARIHARA ENCLAVE

Premises/Building/ 1ST MAIN 15TH CROSS
Road/Street/Lane

Area/Locality/Taluka HSR LAYOUT SECTOR 6

City/Town/District BANGALORE SOUTH,BANGALORE SOUTH,BENGALURU PIN Code 560102

State/U.T. KARNATAKA
Country INDIA
Proof of Address (Correspondence/Permanent)
Aadhaar card √ Passport Voter ID card Driving License Ration Card Registered Lease Sale agreement of residence

Latest Gas Bill Electricity Bill Telephone[Landline] Bill Others (please specify)

5. CONTACT DETAILS
Landline Phone (with STD Code) Mobile + 9 1 9 8 8 6 3 1 6 6 4 9
Email ID [email protected]
Do you want to subscribe to SMS Yes √ No Mobile number is essential for receiving sms alerts regarding your NPS account

6. OTHER DETAILS
Occupation Details

Private Sector √ Government Public Sector Self Employed Professional Agriculture

Homemaker Student Other (please specify)

Please Tick If Applicable Politically exposed Related to Politically exposed

Income Range (per annum) Upto 1 lac 1 lac to 5 lac 5 lac to 10 10 lac to 25 lac √ 25 lac and above

Educational Qualifications Below SSC SSC HSC Graduate √ Masters Professionals ( CA, CS, CMA, etc.)
7.SUBSCRIBER BANK DETAILS:

Account Type Savings A/c √ Current A/c

Bank A/c Number 000201549495

Bank Name* ICICI BANK LIMITED
Branch Name BANGALORE - M G ROAD
Branch Address ICICI BANK TOWERS, 1, COMMISSARIAT ROAD, GROUND FLOOR, BANGALORE560025.

Pin Code * 560025

State/U.T. KARNATAKA
Country INDIA
Bank MICR 560229002 IFS Code ICIC0000002

8. SUBSCRIBER NOMINATION DETAILS*

Name of the Nominee provided

Nominee Name REETU SHUKLA

Relationship with the Nominee WIFE Date of Birth (In case of Minor)

Nominee’s Guardian Details (in case of a minor)

Nominee’s Guardian

9. NPS OPTION DETAILS

I would like to subscribe for Tier II Account YES √ NO (Please tick () as applicable).

10. PENSION FUND (PF) SELECTION AND INVESTMENT OPTION*

(i) PENSION FUND SELECTION (Tier I) :

Name of the Pension Fund PFM Selected

LIC Pension Fund Limited

SBI Pension Funds Private Limited

UTI Retirement Solutions Limited

ICICI Prudential Pension Funds Management Company Limited √

Kotak Mahindra Pension Fund Limited

Reliance Capital Pension Fund Limited

HDFC Pension Management Company Limited

(ii) INVESTMENT OPTION

Active Choice √ Auto Choice

For details on Auto Choice, please refer to the Offer Document.

(iii) ASSET ALLOCATION

Asset Class E C G Total

(Cannot exceed 50%)

% share 50 0 50 100%

11. DECLARATION BY SUBSCRIBER*

Declaration & Authorization by all subscribers

√ I have read and understood the terms and conditions of the National Pension System and hereby agree to the same and declare that the information and
documents furnished by me are true and correct, to the best of my knowledge and belief. I undertake to inform immediately the Central Record Keeping
Agency/National Pension System Trust, of any change in the above information furnished by me. I do not hold any pre-existing account under NPS. I
understand that I shall be fully liable for submission of any false or incorrect information or documents.

√ I further agree to be bound by the terms and conditions of provision of services by CRA, from time to time and any amendment thereof as approved by
PFRDA, whether complete or partial without any new declaration being furnished by me. I shall be bound by the terms and conditions for the usage of I-PIN
(to access CRA/NPSCAN and view details) & T-PIN on the CRA website.

√ I agree to take a printout of the registration form from eNPS portal, paste photograph, affix signature and send it to CRA. I understand that my PRAN will be
‘frozen’ temporarily if the form is not sent to CRA within 90 days from the date of allotment of PRAN. (Applicable only for Aadhaar based Subscriber
Registration).
√
I understand that my initial contribution will be credited in my PRAN but I will not be able to make any further contribution till the KYC compliance is confirmed
by the Bank selected by me during registration. Once the KYC compliance is confirmed by Bank, I agree to take a printout of the registration form from eNPS
portal, paste photograph, affix signature and send it to CRA. I understand that my PRAN will be ‘frozen’ temporarily if the form is not sent to CRA within 90
days from the date of allotment of PRAN. (Applicable to Subscribers registering with PAN and subsequent KYC verification by Bank).
Declaration under the Prevention of Money Laundering Act, 2002
√ I hereby declare that the contribution paid by me/on my behalf has been derived from legally declared and assessed sources of income. I understand that
NPS Trust has the right to peruse my financial profile or share the information, with other government authorities. I further agree that NPS Trust has the
right to close my PRAN in case I am found violating the provisions of any law relating to prevention of money laundering.

Date of Registration: 0 1 / 0 8 / 2 0 1 6

Place :

Signature/Thumb Impression* of Subscriber in black ink

(* LTI in case of male and RTI in case of female)

ACKNOWLEDGEMENT
Name of the Subscriber: RATAN PRASAD GUPTA
Acknowledgement 1 1 1 0 0 4 6 4
PRAN Allotted 1 1 0 0 5 7 6 3 8 8 4 5
Contribution Amount Remitted: 1000.00

Receipt Number 1 2 6 3 9 6 9 5 0 1 9 6 6 7 9 6 3

TO BE FILLED BY CRA
Received by

Received at Date

The subscriber is supposed to submit the physical form along with photograph and signature to CRA at the earliest. If forms are not received within
90 days of PRAN generation, the account will be frozen.

Physical form to be dispatched to the following Address:

Central Recordkeeping Agency (eNPS),

NSDL e-Governance Infrastructure Limited,
1st Floor, Times Tower, Kamala Mills Compound,Senapati Bapat Marg
Lower Parel (W), Mumbai - 400 013.
 Annexure I to eNPS Form
TIER II DETAILS

I hereby submit the following details for Tier – II account .

1. PAN : A I A P G 0 5 8 3 G

2. Subscribers Bank Details:

If same as Tier I √

Account Type Savings A/c √ Current

Bank A/c Number 000201549495

Bank Name ICICI BANK LIMITED

Branch Name BANGALORE - M G ROAD

Branch Address ICICI BANK TOWERS, 1, COMMISSARIAT ROAD, GROUND FLOOR, BANGALORE560025.

Pincode 560025

State/U.T. KARNATAKA

Country INDIA

Bank MICR Code 560229002 IFS Code ICIC0000002

3.Subscriber’s Nomination Details

If same as Tier I √

Name of the Nominee:

First Name Middle Name Last Name

REETU SHUKLA

Date of Birth (In case of Minor)

Relationship with the Nominee:

WIFE

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

First Name Middle Name Last Name

4.Subscriber Scheme Preference

PENSION FUND (PF) SELECTION AND INVESTMENT OPTION*

(i) PENSION FUND SELECTION :

If same as Tier I

Pension Fund Name PFM Selected

LIC Pension Fund Limited

SBI Pension Funds Private Limited

UTI Retirement Solutions Limited

ICICI Prudential Pension Funds Management Company Limited √

Kotak Mahindra Pension Fund Limited

Reliance Capital Pension Fund Limited

HDFC Pension Management Company Limited

(ii) INVESTMENT OPTION

Active Choice √ Auto Choice

(iii) ASSET ALLOCATION

Asset Class E C G Total

(Cannot exceed 50%)

% share 50 0 50 100%

Declaration & Authorization by subscriber

√ I have read and understood the terms and conditions of the National Pension System and hereby agree to the same and declare that the information and
documents furnished by me are true and correct, to the best of my knowledge and belief. I undertake to inform immediately the Central Record Keeping
Agency/National Pension System Trust, of any change in the above information furnished by me. I do not hold any pre-existing account under NPS. I
understand that I shall be fully liable for submission of any false or incorrect information or documents.

√ I further agree to be bound by the terms and conditions of provision of services by CRA, from time to time and any amendment thereof as approved by
PFRDA, whether complete or partial without any new declaration being furnished by me. I shall be bound by the terms and conditions for the usage of I-PIN (to
access CRA/NPSCAN and view details) & T-PIN on the CRA website.

√ I agree to take a printout of the registration form from eNPS portal, paste photograph, affix signature and send it to CRA. I understand that my PRAN will be
‘frozen’ temporarily if the form is not sent to CRA within 90 days from the date of allotment of PRAN. (Applicable only for Aadhaar based Subscriber
Registration).
√ I understand that my initial contribution will be credited in my PRAN but I will not be able to make any further contribution till the KYC compliance is confirmed
by the Bank selected by me during registration. Once the KYC compliance is confirmed by Bank, I agree to take a printout of the registration form from eNPS
portal, paste photograph, affix signature and send it to CRA. I understand that my PRAN will be ‘frozen’ temporarily if the form is not sent to CRA within 90
days from the date of allotment of PRAN. (Applicable to Subscribers registering with PAN and subsequent KYC verification by Bank).

Declaration under the Prevention of Money Laundering Act, 2002

√ I hereby declare that the contribution paid by me/on my behalf has been derived from legally declared and assessed sources of income. I understand that
NPS Trust has the right to peruse my financial profile or share the information, with other government authorities. I further agree that NPS Trust has the right
to close my PRAN in case I am found violating the provisions of any law relating to prevention of money laundering.
I have opted for Tier II and I declare that I will submit copy of PAN Card and cancelled Cheque/Bank Certificate along with the Registration Form to CRA.

Date of Registration: 0 1 / 0 8 / 2 0 1 6
Signature/Thumb Impression* of
Place:
Subscriber in black ink
(* LTI in case of male and RTI in case of female)