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(Administered by Pension Fund Regulatory and Development Authority)

The Branch Manager, _______________________________________________________ Bank______________________________Branch

Dear Sir/Madam,
I hereby request that an APY account be opened in my name under National Pension System (NPS) as per the particulars given below:
* Indicates mandatory fields. Please fill the form in English and BLOCK letters
Bank A/c Number*
Bank Name* Bank Branch*
Name of Applicant Shri Smt. Kumari
Full Name
Date of Birth* d d / m m / y y y y Age Mobile No
Email ID Aadhaar
Married Yes No If married , spouse name is mandatory. Spouse will be the default nominee under APY.
Name of Spouse Aadhaar
Nominee's Name* Aadhaar
Nominee's Relationship with the subscriber
Additional Details in case nominee is a Minor
Date of Birth* d d / m m / y y y y
Guardian's Name*
Whether beneficiary of other statutory social security schemes Yes No
Whether Income Tax Payer Yes No
Frequency of Contribution (Please tick(√)) * Monthly Quarterly Half Yearly
Pension Amount (Please tick(√)) * 1000 2000 3000 4000 5000
I hereby a uthori ze the ba nk to debi t my a bove menti oned ba nk a ccount ti l l the a ge of 60
Contribution Amount for ma ki ng pa yment under APY a s a ppl i ca bl e ba s ed on my a ge a nd the Pens i on Amount
(in Rs.) s el ected by me. If the tra ns a cti on i s del a yed or not effected a t a l l for i ns uffi ci ent
(To be filled by the Bank) ba nl a nce, I woul d not hol d the ba nk res pons i bl e. I a l s o underta ke to depos i t the
a ddi ti ona l a mount together wi th pena l ty thereon.
Declaration & Authorization by all subscribers
I meet the pres cri bed el i gi bi l i ty cri teri a for a s s i s ta nce under APY a nd I ha ve rea d a nd unders tood the terms a nd condi ti ons of the Scheme. I hereby a gree
to the s a me a nd decl a re tha t the i nforma ti on furni s hed by me i s true a nd correct, to the bes t of my knowl edge a nd bel i ef. I underta ke to i mmedi a tel y
i nform the ba nk of a ny cha nge i n the a bove i nforma ti on furni s hed by me. Further, I do not hold any pre-existing account under APY. I unders ta nd tha t I s ha l l be
ful l y l i a bl e for s ubmi s s i on of a ny fa l s e or i ncorrect i nforma ti on or documents . I ha ve rea d/been expl a i ned a nd ha ve unders tood the APY gui del i nes . I
further a gree to be bound by the terms a nd condi ti ons of provi s i on of s ervi ces under the s cheme a s a pproved by PFRDA/Govt. of Indi a .
Date d d m m y y y y Signature/Thumb Impression* of
Place Subscriber (* LTI i n ca s e of ma l e a nd RTI
i n ca s e of fema l e)


(To be filled by the Bank)
Name of the Subscriber:
PRAN Number
Guaranteed Pension Amount
Periodicity of Contribution
Contribution Amount under APY
(in Rs.)
Name of the Bank
Bank Branch:
Receiving Officer's Name:
Date of Receipt of Application: Stamp and Signature of the Bank