Nomination in APY

Bank A/c Number* d d / m m / y y y y Yes No d d / m m / y y y y No No Date d d m m y y y y Place M o n t h l y Q u a r t e r l y Signature/Thumb Impression* of Subscriber (* LTI in case of male and RTI in case of female) To, The Branch Manager, _______________________________________________________ Bank______________________________Branch Dear Sir/Madam, I hereby request that an APY account be opened in my name under NPS as per the particulars given below: Yes * Indicates mandatory fields. Please fill the form in English and BLOCK letters 1. BANK DETAILS: Shri If married , spouse name is mandatory. Spouse will be the default nominee under APY. Bank Branch* Bank Name* Date of Birth* Kumari Name of Applicant in full Married Aadhaar Mobile No Guaranteed Pension Amount PRAN Number 3. PENSION DETAILS Name of Spouse Yes ACKNOWLEDGEMENT - SUBSCRIBER REGISTRATION FOR ATAL PENSION YOJANA (APY) (To be filled by the Bank) Name of the Subscriber: 4. Peridocity of contribution payments (Tick one) Quarterly Monthly ATAL PENSION YOJANA (APY) - SUBSCRIBER REGISTRATION FORM (Administered by Pension Fund Regulatory and Development Authority) Full Name Pension Amount (Please tick(√)) * 2. PERSONAL DETAILS: Nominee's Name* Age 3000 4000 5000 Smt. Email ID 1000 Guardian's Name* Date of Birth* Additional Details in case nominee is a Minor Nominee's Relationship with the subscriber Receiving Officer's Name: Date of Receipt of Application: Stamp and Signature of the Bank Name of the Bank Bank Branch: Monthly Contribution/ Quarterly Contribution Amount under APY Periodicity of Contribution (Tick one) Declaration & Authorization by all subscribers I meet the prescribed eligibility criteria for assistance under APY and I have read and understood the terms and conditions of the Scheme. I hereby agree to the same and declare that the information furnished by me is true and correct, to the best of my knowledge and belief. I undertake to immediately inform the bank of any change in the above information furnished by me. I understand that I shall be fully liable for submission of any false or incorrect information or documents. I have read/been explained and have understood the APY guidelines. I further agree to be bound by the terms and conditions of provision of services under the scheme as approved by PFRDA/Govt. of India. 2000 Contribution Amount (Monthly/Quarterly ) (in Rs.) (To be filled by the Bank) I hereby authorize the bank to debit my above mentioned bank account till the age of 60 for making payment under APY as applicable based on my age and the Pension Amount selected by me. If the transaction is delayed or not effected at all for insufficient banlance, I would not hold the bank responsible. I also undertake to deposit the additional amount together with penalty thereon. Whether Income Tax Payer Half Yearly Aadhaar Aadhaar Whether beneficiary of other statutory social security schemes A B A and B should be different names. A - Spouse B - Nominee ,the recipient of pension corpus after the death of the Subscriber and the spouse