NATIONAL PENSION SYSTEM (NPS)

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

Non Aadhaar based registration

Affix recent colour
To, photograph of 3.5
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 * K N E E L A K A N T A N
Middle Name

Last Name

Date of Birth * 1 4 / 0 3 / 1 9 7 3

Gender * Male Female Others

Father's Name* N K R I S H N A N

2. IDENTITY DETAILS*

PAN A C K P N 9 7 8 7 H Aadhaar 8 7 1 3 2 0 2 0 0 1 9 6 Voter ID

Passport Others

3. CORRESPONDENCE ADDRESS DETAILS*

Flat/Room/Door/Block no. PLOT 139 DOOR 4/15

Landmark KRISHNAMACHARI NAGAR

Premises/Building/Village 6TH STREET

Road/Street/Lane

Area/Locality/Taluka ALAPAKKAM
City/Town/District PORUR,AMBATTUR,TIRUVALLUR PIN Code 600116
State/U.T. TAMIL NADU
Country INDIA

4. PERMANENT ADDRESS DETAILS: Tick ( ) in the box in case the address is same as above.
Flat/Room/Door/Block no. PLOT 139 DOOR 4/15

Landmark KRISHNAMACHARI NAGAR

Premises/Building/ 6TH STREET
Road/Street/Lane

Area/Locality/Taluka ALAPAKKAM

City/Town/District PORUR,AMBATTUR,TIRUVALLUR PIN Code 600116

State/U.T. TAMIL NADU

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 4 4 4 3 4 6 6 2 1
Email ID KRISHNAN.NEELS@GMAIL.COM
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 208500101010179

Bank Name* CORPORATION BANK
Branch Name CHENNAI LSI EC
Branch Address 100-A RADHA AVENUE, SRI LAKSHMI NAGAR, VALASARAVAKKAM, CHENNAI 600087

Pin Code * 600087

State/U.T. TAMIL NADU

Country INDIA
Bank MICR 600017020 IFS Code CORP0002085

8. SUBSCRIBER NOMINATION DETAILS*

Name of the Nominee provided

Nominee Name BRINDHA LAKSHMI

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

Nominees Guardian Details (in case of a minor)

Nominees 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 A Total

(Cannot exceed 50%)

% share 43 18 39 100%

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

I hereby declare that I am the bonafide subscriber of NPS and the contribution being paid for this transaction pertains to my PRAN. I further declare that
I will make payment from my bank account.
Declaration under the Prevention of Money Laundering Act, 2002
I hereby declare that the contribution paid by me has been derived from my 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: 2 4 / 0 2 / 2 0 1 7

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: K NEELAKANTAN
Acknowledgement 1 1 2 2 4 2 7 3
PRAN Allotted 1 1 0 1 2 1 0 2 7 3 7 3
Contribution Amount Remitted: 2000.00

Receipt Number 1 2 6 3 9 6 9 5 0 1 9 1 0 3 8 8 0

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 C K P N 9 7 8 7 H

2. Subscribers Bank Details:

If same as Tier I

Account Type Savings A/c Current

Bank A/c Number 208500101010179

Bank Name CORPORATION BANK

Branch Name CHENNAI LSI EC

Branch Address 100-A RADHA AVENUE, SRI LAKSHMI NAGAR, VALASARAVAKKAM, CHENNAI 600087

Pincode 600087

State/U.T. TAMIL NADU

Country INDIA

Bank MICR Code 600017020 IFS Code CORP0002085

3.Subscribers Nomination Details

If same as Tier I

Name of the Nominee:

First Name Middle Name Last Name

BRINDHA LAKSHMI

Date of Birth (In case of Minor)

Relationship with the Nominee:

WIFE

Nominees 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 A Total

(Cannot exceed 50%)

% share 43 18 39 100%

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).
I hereby declare that I am the bonafide subscriber of NPS and the contribution being paid for this transaction pertains to my PRAN. I further declare that I
will make payment from my bank account.

Declaration under the Prevention of Money Laundering Act, 2002

I hereby declare that the contribution paid by me has been derived from my 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: 2 4 / 0 2 / 2 0 1 7
Signature/Thumb Impression* of
Place:
Subscriber in black ink
(* LTI in case of male and RTI in case of female)