NATIONAL PENSION SYSTEM (NPS)

Exit from National Pension System Due to Premature Exit

- - -
Claim ID
Ackn~wl_edgement No
To,
NPSTrust.
Sir/Madam,

l,~L::-A:'.L-~~~l)..\=1'-J=L=-
\-4-J
~~- - - - - -
of the accumulated pension wealth in my NPS TI _ hereby apply for the payment
1
withdrawals under NPS) Regulation 2015 ter account as per the relevant provisions of the PFRDA (Exits and

roP
s, as amended
lier 11:- The entire accumulated pension wealth in .
lier I account. lier II account would be paid along with lumpsum withdrawal of

I herewith give below the necessary details:

*In case of female right thumb Impression and in Signature / Thumb Impression•
. . case of male left thumb Impression may be taken.
of the Subscriber
" -$r.N°' · I .. .l "~cular
I Remaru
Section A - Subscriber's Personal.Details
Subscriber Sector'"
1. Govt. Sector
2. All India citizens/corporate
'- z
3. NPS Lite/ GOS
1. Organisation Name• (PAO/DTO/CHO/NLAO N )
2. PRAN* ame
3. -F ull~•
/ ...J,d ./
4. Subscriber Gender"
5.
Male Female LJ
~-kM <: o 'T HM-.:).
Father's Name•
6. Marital Status*
Married fV7 Unmarried/others C
7. Maiden _Name (In case of female married subscriber)
8. Spouses Name (only if subscriber is married & spouse is alive)
9. Spouse Gender (only if subscriber is married & spouse is alive)
10.
Male CJ Female £:::]
Date of Reslgnali~ DD / MM / YY"r"(
11. Date of Birth (As in PRAN Card)* D~ I 0~1 / IC\~
12. AadharNID ? I D \.\ h q / l\1-6 ":f -=f'\..\ U: 1--- .0-1 \
13. PAN*
14. CKYCNumber
15. Ive you a P-Olilically Exposed P-erson (PEP)* ves D No ~
16. Are you related to a Politically Exposed Person (PEP)* Yes L J No \SZJ
17. Do you have any history of conviction under any criminal
proceedings in India or abroad?* Yes D No V I
If Yes, please provide details
18. Contact details Mobile number" : +91 1 'st)'() lg ; ··-6."\
Alternate phone fl\Jfflber :
E-mail ID* : \ e.o 01\t..J. \-e 3 \ & ~Mc.!.,'. ~t:>1\/\
Subscriber's full address with pin code* (.,( 1) I) kN'- t) I"' '11-1
•c.'L~~ N}l~~%~c. ~q.i ~f:tt,'CA.
19. 1 __,,
(Please refer instruction No. 10 for documents to be submitted) f>A
Section B - Subscriber's Bank Details - (Please refer instruction No. 7)

20. Bank Account Number*#; 0 \ %,\ () \.,\ b (;;()C\C'l"l \,\ C\

21. Bank Name*
22. Bank Branch Name and Address : The monthly pension and lump
sum amount would be deposited into this account and hence fill
in an the details carefully.•
23. IFSC Code (attach a cancelled cheque leaf or copy of bank
passbook /bank certificate containing IFSC code)*
Fields marked with • are mandatory, # Should re same where last sala,y credited mcase of Government sectorlCorporat subscribers

Section C - Subscriber's withdrawal Details - (Please refer instruction No. 8)

Before attaining superannuation or attaining 60 / 65 years of age
a) Would you like to withdraw full amount (if less than or equal to 1 lakh) Yes D No D

b) Would you like to have nom:iWithdrawal (Lump sum & Annuity Wtthdrawal)' Yes 6 No D
# Please pnwide the Pen:enmge of corpus that you wish w opt for Jump sum withdrawals and purchaSe ol annuity
Percentage of corpus opted for purchase of Total (100%)
% ol oorpus opted for lump sum withdrawal
(Max20%) annuity (Min 80%)
 . 0 ( complete withdrawal)
Section D • Subscriber's Annuity Details (Please refer instruction No. 15 & 16) (Not to be filled in case

Select Annuity Service Provider (please tick one of the below options as per your choice)
[] Life Insurance Corporation of India D HDFC Life Insurance Company Ltd

ICICI Prudential Life Insurance [] SBI Life Insurance Company Lid

D Star Union Dai-ichi Life Insurance Company Limited

Select Annuity Scheme (please tick one of the below options as per your choice)
Annuity for Life
Annuity for Life with return of purchase price on death
Annuity payable for life with 100% annuity payable to spouse on death of annuitant
Annuity payable for life wilh 100% annuity payable to spouse on death of annuitant with return on purchase of annuity

D NPS-Family Income option (Default annuity)

D Other (Please Specify)

Select Annuity Frequency: Please tick one of the below options as per your choice. (For Government Subscriber, annuity frequency is monthly only)
Monthly O auarterty Yearly

Date: Ot\iI (J~ I '()-0'2.J::;, • Sig

r resslon of the Subscnber
.
"In case of female right thumb Impression and in case of male left thumb Impression may be taken •
Section E • Subscriber's Nomination Details*

Nomination Details: Applicable to those eligible sums as per regulations. Name : t:) l:\iVl ( b M'f\-:l .¼00 '6{,
Nominee must be immediate family member of subscriber (Spouse, Children Relationship : f- Pf\ H i::(l_ Percentage Share: S7 ,
etc) in general except for exceptions as provided in Regulations. Date of Birth of Nominee (Only in case of minor) : ,:,::. I ,. ' I '
Guardian Name (Only in case of minor)
Guardian DOB (Only in case of minor)
Address & Contact Details :

Guardian Signature (Only in case of minor)

'fcl ~\-\ c~
Name: I~
Relationship : N'--Oi \-H:::~... Peroentage Share:~ D
Date of Birth of Nominee (Only in case of minor) : ,· / ·· · I
1,
Guardian Name (Only in case of minor)
Guardian DOB (Only in case of minor)
Address & Contact Details :

Guardian Signature (Only in case of minor)

Name:
Relationship : Percentage Share:
Date of Birth of Nominee (Only in case of minor) : - ·:, I '- . I ,· .
Guardian Name (Only In case of minor)
Guardian DOB (Only In case of minor)
Address & Contact Details :

Guardian Signature (Onlv in case of minor)

Section F - Subscriber's Family Member Details* (To be filled in case subscriber has selected Joint Life PoHcy or NPs-Family Income option)

Family Member Details for providing annuity as chosen by t h e ~-

~---
-- - p~ Date of Bli'ttl
('adharMD
~II~ FuJIN,ame ~--- . - fl[' / !,. - ' / ' " 'y
1. Spouse' y; I i'v' '.! / ': ., y
2. Dependent Mother (if living) C'" / t. 'i,\ I ·1 \ " -.
3. Dependent Father (If llving) c,.:_, J \,~ • J ' 1 '- Y'
4. Chld 1 (rf lvlng) DC / i.' ·• I ,•v\'
5. Child 2 (If living) :''fr / .l /\"'r
'
6. Chid 3 (If lvlng)
Note: In ca. of chlklren being more than 3, please specify In an additional sheet
Aelds marked with* are mandatory.
'Mandatory in case subscriber opts for Joint Life Polley & NPS-Family Income option

I
Declaration by the Subscriber th
1
11hereby declare 8nd state that all the personal details provided by me in the form as above are true and correct to the best of my knOWledge. also ag~ toat
NPS Ti /C ct d tails including detalls pertaining
rust RA shall not be held responsible/liable for any losses or delays that may arise due to provision of incorre e . . . 1
bank acoount details provided by me. Further, I authorize the National Pension System Trust (NPST}' CRA to share informations pertaJnmg to my withdrawa
application with the Annuity Service Providers for facilitating the purchase of annuity In applicable cases as is required under NPS.

Date , 0'VO"/~'.l.-"3 ••,~ ....................

•tn case of female right thumb Impression and In case of male left thumb Impression may be taken.

Declaration by the Proposer: (Not to be filled In case of complete withdrawal) . .

I hereby declare that the foregoing statements and infonnatlons have been given by me after fully understanding the questions and the annuity options th8t and the
same are ~e. 8:ccurate and complete in every manner and that I have not withheld or omitted to give any material information . I understand and agree the
statements m this proposal constitute warranties. I do hereby agree and declare that these statements and this declaration shall be the basis of the contract of
assurance _belwe9!1 me and ~nu!ty Service Provider (Company) and that If there be any misstatement or suppression of mate~al information or if any untrue
statement 1s conta•~~ therein or in case of fraud by me, which comes to the knowledge of the company at any future P_Oint of ':""e, the said contract shall be
treated as per- proV1S1ons of Section 45 of the lnsuran~ Act 1938 or any other applicable provisions as amended from time to ume.
I a~ u ~ n d and ag~ that the ~mpany shall additionally levy or recover all the apptlcable taxes like service tax, surcharges, cess etc. from the
premurns which are necessitated by venous enactments of central and/or state legislatures from time to time.
I understand that the _c ontract will be governed by the provisions of the Insurance Act. 19 38, and other applicable lawS In India and ~t the contracl wil not
com~ce until. a wntten acceptance of this proposal is issued by the company and that the benefits under the policy shall be subJect to the tenns and
conditions contained In the contract. I also agree that the amount held In proposaUpolicy deposit shall not eam any Interest •
I further state that the product features and terms and conditions of the policy have been thoroughly explained to me and having understood. I consent to the
same.
I further understand that the final annuity amount would be subject to the actual corpus value to be utilised for purchase of annuity at the time of_its issuance.
I also acknowl~dge and agree that the funds will not be returned to me in case I choose to cancel the policy under free look period. 'f!lese funds wi(I be payable
by company directly to any other annuity scheme chosen by me which is authorized and approved under the prevalent regulations and applicable rules.
Further, no Interest will be payable to me on the funds held during this transition period.
I hereby authorize company to send information and servicing related communication regarding this proposal or resulting policy through Email/SMS/Phone Call.
I hereby authorize the company to provide me/our details to banks, financial Institutions and third party service providers that the company may have tie-ups
with, for verification of proposal details and for servicing of policies.

Signature / Left thumb Impression of the

Proposer
Signature of the witness

Affix a recent self signed

photograph I

Name and Address of witness:

Place:

l'' / ,_. 1· ''

Date:

othe than proposer/proposer signs In a vernacular language/proposer Is Illiterate

Declaration when Proposal fonn ts fflled by penlon r
(Not to be filled in case of complete withdrawal)
ime state that the product details, contents of
the contents of this proposal form and all other
this fonn and re~vant documents have been
I hereby state that I have read out and explained language, he/she/they have
fully explained to me/Us and that I/We have fully
relevant documents to the proposer in d conditions of the resulting policy and have
understood them. I/We certify that the replies In
understood the same and agree to abide by ~e ren:ea ~ I tonn in my presence.
affixed his/her/their signature/thumb impression on the proposal fonn '?lave been recorded as per
the lnfomlatlon provided by me/US.

Signature of the person

making the declaration
Name &Address - -- - - - - - - - - - - - - - - - - - - - - - - -

Signature / Lei\ thumb Impression of the

Proposer
 Section G - Declaration & AttestaUon by Nodal Office
TO BE FILLED/ATTESTED BY 000/PAOIPOP-SP . f th blect claim
1. 11wa have verified the documents as submitted by the Subscriber with the originals and authorized this application for processing O e su 1 cord
cl the subscriber. It is certified that the details as provided In this appllcaUon form are matching with the lnformaUon available In the offlclal re
mainlained by us.. The complete lnfonnallon provided In this form including declaration and nomination details have been provided by the su,bscrltrlber
Sh/Smt/Ms.. - - - - -- -- - - - - - -- -- -- - - - - - -- -- -- after he/ she having read the entries en ••
haw been read over to him / her by me and got conflrmed by him / her.
2. That all the conlributlons with respect lo the Subscriber's NPS contribution and employer contribution have been lranllferred In to the PRAN of the
subscriber and no further contributions are pending at Nodal Officer level. (only for government nodal office)
3. That Identity of the Subscriber Is certified as provided in the withdrawal form above. The name of Subscriber as mentioned on the withdrawal form has
been verified and can be accepted as final.
-4. II is certified that the bank account (Salary Account) details provided in the form is as per the salary records maintained in our office. The bank account
delah (salary account) of subscriber as provided in bank details section have been checked and verified and the same can be accepted for payment
(only ror government nodal office).

Rubber Stamp of the 000/POP-SP/NLCC

Signature of the Authorised Person

000/POP-SP/NLCCReglstrationNumber _ _ _ __ _ __ _ __ _ _ _ _ _ __ _ _ _ _ __ _ _ _ _ __ _ __ _ __

Designation of the Authorised Person : _ _ _ __ _ __ _ __ _ _ 000/POP-SP/NLCC Office Name: _ _ _ __ _ _ _ _ __ _ _ _

Rubber Stamp of the DTO/PAO/POP/Aggregator

Signature of the Authorised Person

DTO/PAO/POP/AggregatorReglstrationNumber _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ __

Designation of the Authorised Person : _ _ _ _ _ _ _ _ _ _ _ _ _ _ OTO/PAO/POP/ Aggregator Office Name: _ __ _ _ __ _ __

[As per Regulation 3(b)/4{b)/5(b) of PFRDA (Exits and Withdrawals) under the Regulations, 2015)
(To be filled in case of complete withdrawal)
Request cum under taking form for wtthdrawaJ of total pension wealth before the age of superannuation and where the total pension wealth Is
equal to or less than rupees 1,00,000/-.
_ _ _ _ __ _ _ _ _ _ _ __ _ _ _ __ SIDN.Jlo, _ _ __ _ __ _ _ __ _ _ , aged about _ __ _ __ _ _ years,
I,
residing at _ _ __ _ __ __ _ _ _ _ _ _ _ __ __ _ _ _ _ _ _ _ _ _ __ _ do hereby solemnly affirm and declare as under:

1. That I am a Subscriber of National Pension System, holding PRAN - - - - - - -- - - - - -

2. That since the total amount receivable by me as the bethnefit re ceiva~le uponthexit dfromNNPPSrui s Rs/sg.u~dheitlneiss less than/equal to the limit of Rs. 1,00,000I-,
1understand that I am eligible to opt for withdrawal of e tota 1pension wea1 un er 5 18 ,
Basing on the above, 1 hereby opt to withdraw my complete pension wealth lying to my credit in my aforesaid PRAN account being the full and final
benefits receivable by me. th N ti 1
· · · d I I family members shall not be entitled to receive any other or further benefits under e a ona
I also understand that with th~ aforesaid with rawa ' ldordmy d PFRDA (Exits and Withdrawals under the National Pension System) Regulations 2015.
Pension System (NPS) Including the benefits as prov e un er

Date: _,. / ,·., / ·

• Signature/Thumb Impression of the Subscriber
Place:

*In case of female right thumb impression and in case of male left thumb impression may be taken.

1
Date i ' .i ' I ! ,- • ' 11
I -

Registration No. of D00/POP-SP/ NLCC

Signature of the ODO/POP-SP/ NLCC
Rubber Stamp of the ODO/POP-SP/ NLCC

Date ,( t l \: d-, 1 -,1

1
i I ·1

Regl~traU;n No. of
Signature of the DTO/PAO/POP/ Aggregator
Rubber Stamp of the OTO/PAO/POP/Aggregator
oTOJPAOIPOPfAggregator