NATIONAL PENSION SYSTEM (NPS) - SUBSCRIBER REGISTRATION FORM - Private Sector

How did you hear about NPS Friend/ family √ Social media Newpaper/magazines TV / Radio Financial advisor Employer

PRAN Card & Kit* i. PRAN Card & Kit* (please tick()) ii. Account Opening Kit (please tick())
(refer sl no.1 of
instructions) √ ePRAN Card Physical PRAN Card √ Through Email Physical Kit (Courier)

Print my PRAN in Hindi YES √ NO If Yes, submit details as per Annexure I

Select your category* Corporate √ All Citizen

To,
National Pension System Trust.
Dear Sir/Madam,
I hereby request that an NPS account be opened in my name as per the particulars given below :
* indicates mandatory fields. Please fill the form in English and BLOCK letters (Refer general guidelines at instructions page).

CKYC Identifier 30000359694393 RA Code

1. PERSONAL DETAILS: (Refer Sl no. 1 of instructions) Use Annexure II if name exceeds the space provided below

Salutation* √ Shri Smt. Kumari

Applicant Name* KOUSHIK PAL

Father's Name JAYDEB PAL

Mother's Name

Either Father's or Mother's name is mandatory* Select the name to appear on PRAN Card √ Father's Name Mother's Name

Date of Birth* 24/11/1993 Applicant is Orphan*

Place of Birth* BURDWAN

Country of Birth* INDIA

Gender* √ Male Female Transgender Nationality* INDIAN

Marital Status* Unmarried √ Married Widow/Widower Divorcee

Spouse Name (if married)* ANANYA DAN

PAN Card* CSYPP3479G or Form 60 furnished Submission of PAN or Form 60 is mandatory

Income Range (per annum) Below 1 lac √ 1 lac to 5 lac 5 lac to 10 lac 10 lac to 25 lac 25 lac to 1 Cr Above 1 Cr

Occupation Details* Public Sector √ Private Sector Professional Self Employed Homemaker Others

Please Tick If Applicable Politically exposed person Related to Politically exposed person (Refer instruction no. 1)

2. PROOF OF IDENTITY AND ADDRESS* (Refer Sr. No. 2 of the instructions)

Passport Passport Expiry Date

Driving License Driving License Expiry Date

Voter ID Card Proof of possession of Aadhaar Provide last four digits

PoP Certificate
NREGA Job Card National Population Register (refer section 12

3. ADDRESS DETAILS* (As per the proof submitted)

Line 1 PARUI PALRARA KURMUN PURBA

Line 2 BARDHAMAN BURDWAN 19 BARDHAMAN

Village / City INDIA 713102 713102

District BARDHAMAN, PURBA BARDHAMAN State/U.T. WEST BENGAL

Country INDIA PIN Code 713102

4. CONTACT DETAILS
Mobile* +919382597965 Telephone (with STD code)

Email ID* [email protected]

5. BANK DETAILS* (Proof to be submitted. Refer Sl no. 3 of instructions)

Account Type √ Saving A/c Current A/c

Bank A/c Number 0541000103107341

Bank Name PUNJAB NATIONAL BANK IFS Code PUNB0054100

6. NOMINATION DETAILS* (Refer Sl no. 4 of instruction)

A. The nomination shall be in favour of one or more persons belonging to his/her family. For nominating more than one person, submit Annexure III
B. A fresh nomination shall be made by the subscriber on his/her marriage.
Form submitted using OTP
Nominee Name ANANYA DAN Authentication (through Email and
Mobile)
Relationship SPOUSE Date of Birth (In case of Minor) 06-03-2024 10:02:58
Name of Guardian
Age 27
(if nominee is a minor)
 7. SELECTION OF PENSION FUND (PF) AND INVESTMENT CHOICE* (Refer Sl no. 5 of instruction)
1. Maximum equity allocation under active choice is restricted after 50 years of age. Refer instructions carefully before allocating percentage share in equity.
2. All Citizen: Selection of one PF is mandatory else form will be rejected. If no investment choice is selected, funds will be invested in Auto Choice (LC 50).
3. Corporate Model: The PF / Investment Choice may be exercised in consultation with your Employer.

Investment Choice (Please Tick ( ) One )

Active Choice mention the % share in each asset
Asset Class % Allocation Pension Fund

E (upto 75%)

C (upto 100%)
G (upto 100%)

A (upto 5%)
Total 100%
√ Auto Choice select one life cycle fund below

ICICI PRUDENTIAL PENSION FUNDS

PFM

Conservative (LC 25) Moderate (LC 50) Aggressive (LC 75 )

8. Activate my Tier- II account (Please tick () to activate) - refer Sr no 7 of instructions Providing PAN is mandatory

with the same bank, nominee & investment details with different bank/nominee/investment details as per Annexure IV

9. FATCA* (Foreign Account Tax Compliance Act) & CRS DECLARATION (Refer Sr no. 6 of instructions)

√ I am a tax resident of India and not resident of any other country I am a tax resident of the country/ies mentioned below
US Person Yes √ No

Particulars Country (1) Country (2) Country (3)

Country/countries of Tax Residency INDIA

Address Line 1 VILL-PARUIPO-KURMUN

Address in the jurisdiction for City/Town/Village BURDWAN

Tax Residence
State WEST BENGAL

ZIP/Post Code 713102

Tax Identification Number (TIN)/Functional equivalent Number CSYPP3479G
TIN/ Functional equivalent Number Issuing Country INDIA
Validity of documentary evidence provided (Wherever

I have understood the information requirements of this Form (read along with the FATCA/CRS Instructions
and Terms & Conditions) and hereby confirm that the information provided by me/us on this Form is true, Signature/Thumb Impression* of Applicant (refer
correct, and complete and hereby accept the same. instructions)

10. DECLARATION BY APPLICANT* ( Refer Sr no. 7 of the instructions )

I have read and understood the terms and conditions of the National Pension System. The information and
documents furnished by me are true and correct, to the best of my knowledge. Any changes in the
information furnished by me shall be informed to CRA / NPS Trust. 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
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 Signature/Thumb Impression* of Applicant
my PRAN in case I am found violating the provisions of any law relating to prevention of money laundering.
(*LTI in case of males and RTI in case of females to
Date: Place: be provided. Toe impression in case no hands)
06/03/2024
 11.DECLARATION BY EMPLOYER - Only for Corporate sector (All Details are Mandatory)
Date of Retirement

Employee Code/ID Non-mandatory if not available

CHO Registration Number CBO Registration Number

It is certified that is employed with us and the details provided in this

in this subscriber registration form including the address and employment details provided above are as per the service record of the employee maintained with us.
The given address and the documents are verified by this office. Also, it is further certified that he/she has read entries/entries have been read over to him/her by
us and got confirmed by him/her.

Name of the Authorised Person

Designation of Authorised Person

Date

Place Signature of the Authorised person Rubber Stamp of the Employer

12. TO BE FILLED BY POP

Receipt No. (17 digits)

POP Registration Number 5000682 POP-SP Registration Number 6396950

Documents Received:

KOUSHIK PAL
Existing Customer: I/we hereby certify/confirm that Shri/Smt/Kum..........................................................................................................................................................is an
existing KYC verified customer. The above applicant is having an operative Bank/ Demat/ Folio/ ................................. account (specify nature of the account) having
account number /client ID ........................................................... maintained at.......................................................... branch/office. The KYC documents available with us
for this customer/client matches the requirement for opening NPS account and are in compliance with PMLA Rules.

I/We further confirm that the Savings Bank a/c of Sh/Smt/Kum............................................................................................................................

KOUSHIK PAL
is not a Basic Savings Bank Deposit Account (applicable in case of Bank PoP)
Name of the Authorised Person

Designation of Authorised Person

Date

Place Signature of the Authorised person Rubber Stamp of the PoP

ACKNOWLEDGEMENT

Name of the Subscriber: KOUSHIK PAL

Date of Receipt of Application: 06/03/2024

Initial contribution amount

PRAN Allotted/ Acknowledgement ID 11486149

Stamp and Signature of PoP
Mode of payment Cheque / DD Debit instruction Cash
 INSTRUCTIONS FOR FILLING THE SUBSCRIBER REGISTRATION FORM
General Guidelines

(a) Please fill in legible handwriting to avoid errors. Do not overwrite. Corrections should be countersigned by the applicant. Applications incomplete in any
aspect (or) if mandatory fields are left blank (or) with unclear photograph (or) not accompanied by required documents (or) not authenticated by PoP/PoP-SP
are liable to be rejected. (b) Copies of documents submitted by the applicant should be self-attested. (c) Applicant is advised to retain the acknowledgement slip
signed/ stamped by the PoP/PoP-SP office.

Sl Item No Item Details Instructions

In case a subscriber opts not to have a physical PRAN Card or Welcome Kit, reduced account opening charges of
CRA are applicable as under:
Account opening with ePRAN card (in Rs.)
Option for PRAN Card
Account opening with Physical PRAN card (in Rs.)
and Kit
Welcome kit sent in hardcopy Welcome kit sent vide email only

1 1
Father's Name, (a) If the name has more than 30 digits, fill Annexure II for the same. (b) If the applicant is an orphan, he/she may
Mother's Name leave the fields blank. However, an official document to support the status to be submitted

Politically Exposed Persons’(PEPs) are individuals who are or have been entrusted with prominent public functions
Politically Exposed
such as heads of state or of the government, senior politicians, senior government, judicial or military officials, senior
Person
executives of state-owned corporations, important political party officials.

2 2 Proof of Identity and If the applicant is submitting Aadhaar as proof of Identity and Address, the first 8 digits of the Aadhaar number should
Address be redacted / masked on the submitted copy

3 3 Current Address Details Providing current address is mandatory. The submitted address proof should contain the currrent address as provided
in the form

For Tier I & Tier II account, bank details and documentary proof are mandatory. Please submit a cancelled cheque /
4 5 Bank Details copy of bank passbook / bank statement / bank certificate / letter from Bank containing applicant's Name, Bank Name,
Bank Account Number and IFS Code.

(a) If a subscriber has family at the time of making a nomination, the nomination shall be in favor of one or more
persons belonging to his/her family.Any nomination made in favour of a person not belonging to family shall be invalid;
A fresh nomination shall be made by the subscriber upon marriage and any nomination made before such marriage
5 6 Nomination Details shall deemed to be invalid; If at the time of making a nomination the subscriber has no family, the nomination may be
in favor of any person or persons but if the subscriber subsequently acquires a family, such nomination shall forthwith
be deemed to be invalid and the subscriber shall make a fresh nomination in favour of one or more persons belonging
to his family. (b) In case of more than one nominee, the percentage share for each nominee should be in whole
numbers and must be equal to 100.

In active choice the maximum allocation in Equity can be upto 75% for Tier 1
Selection of Pension
7 7
Fund (PF) & Investment Corporate applicants may exercise these choices if the option is extended to them by the employer or else may be
Choice

Clarification / Guidelines on filling details if applicant residence for tax purposes in jurisdiction(s) outside India:
• Jurisdiction(s) of Tax Residence: Since US taxes the global income of its citizen, every US citizen of whatever
nationality, is also a resident for tax purpose in USA.
• Tax identification Number (TIN): TIN need not be reported if it has not been issued by the jurisdiction. However, if
the said jurisdiction has issued a high integrity number with an equivalent level of identification (a "Functional
FATCA & CRS
8 9 equivalent"), the same may be reported. Examples of that type of number for individual include, a social
Declaration
security/insurance number, citizen/personal identification/services code/number and resident registration number)
• In case applicant is declaring US person status as 'No' but his/her Country of Birth is US, document evidencing
Relinquishment of Citizenship should be provided or reasons for not having relinquishment certificate is to be
provided.
• In case applicant is declaring US person status as 'Yes', provide PAN and 'father name' in addition to details
required under section 9 of form
Asset Class A is not available under Tier-II. In case Subscriber has selected to activate Tier-II Account with Same
9 8 Tier-II activation Bank, Nominee and Investment details that of Tier-I whereas he/she has chosen allocation in Asset Class A for Tier-I
account, the applicant would be required to submit the Annexure IV for TierII mentioning the asset allocations

In case the applicant is unable to affix signature, Left Thumb Impression in case of male and Right Thumb Impression
Declaration / Signature in case of female should be affixed and in case there is no hands, toe impression of the applicant to be provided. The
10 9 & 10
by Applicant thumb / toe impression should be attested by two persons, one of whom should be the designated nodal officer
attesting the same under his/her official seal and stamp.

Applicable CRA charges: Protean Kfintech CAMS

Account Opening charges
Account Maintenance Charges
Charge per transaction
 Annexures - Subscriber Registration Form for Private Sector applicants (Tick and fill applicable annexures below)

Annexure I - Print PRAN Card in Hindi (Fill the details in Devnagri script)

Applicant's First Name

Middle Name

Last Name

Father/Mother's First Name

Middle Name

Last Name

Annexure II - If alphabets of name exceeded the space provided on page 1 of the application form
Applicant's First Name

Middle Name

Last Name

Father's First Name

Middle Name

Last Name

Mother's First Name

Middle Name

Last Name

Annexure III - Additional Nomination For Tier-I For Tier-II For both Tier-I & Tier-II

Percentage Share Nominee I 100 Nominee II Nominee III Total should be equal to 100%

Nominee I - Name ANANYA DAN

Nominee I

Relationship SPOUSE Age 27 Date of Birth (In case of Minor)

Name of Guardian
(if nominee is a minor)

Nominee II - Name
Nominee II

Relationship Age Date of Birth (In case of Minor)

Name of Guardian
(if nominee is a minor)

Nominee III - Name

Nominee III

Relationship Age Date of Birth (In case of Minor)

Name of Guardian
(if nominee is a minor)

Annexure IV - Activate Tier-II with Different Bank/Nomination/Investment Details - tick and fill as applicable

PAN* Copy of PAN to be attached

No change in Bank details Bank details for Tier-II are as under:

Account Type Saving A/c Current A/c

Bank A/c Number

Bank Name IFS Code

No change in Nominee details Nominee details for Tier-II are as under:

Nominee Name

Relationship Age Date of Birth (In case of Minor)

Name of Guardian
(if nominee is a minor)

In case you desire to nominate more than one person, fill Annexure III above

No change in Investment details #only selection of PF is required

Investment Choice (Please Tick ( ) One )

Active Choice mention the % share in each asset
Asset Class % Allocation Pension Fund*
E (upto 75%)

C (upto 100%)
G (upto 100%)

Total 100%

Auto Choice Select one life cycle fund below

PFM

Conservative (LC 25) Moderate (LC 50 ) Aggresssive (LC 75)

Name of the Applicant KOUSHIK PAL

Place

Date 06/03/2024

Signature / Thump Impression* of Applicant (refer

instructions)