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➢
Section-A : Subscriber' s Personal Details (&4i2t.1z1/vt.[ti.4iz1-U Zl.°ld >t&dl) 1. Full Name ('w -wt) : -tc[l 4.Kd 4-kVt ^lL°tf-tl' "tLcj ^t.St(3 -z bilc-lCL& 4.^.a bt1 iGt 4 121 al LC%. 2. Gender (cnR) : &ii^ll2l^zi[F{§l21'[[
°n(h EYllgdl.
3. Date of Birth (K-1i diZ."t) : A u 1/b.['&lzl-t1 iLWiMl tiw1 EEli&c-L °e- -L dtz1xi DD/MM/YYYY Li e2ti c-14tH. 4. Pan No . (4Ld 4W.z) : SZiRlzl/ZiMlz1-'LL 414 -V'R.
5. Farher ' s Full Name ((^4.di j -ti>t) : k2{^llzl^zl [EIslZ1 it [4.dt. '{j? -alt E act%. 6. Present Address (ctc u4 aZ-Wi) S4^ltzl/btR..4121 ciA -tilt % 2{Z-t1I'i (3'1ci.G{ 46 6 il'L cSt4 cl -Pt A z1-t1 2§I VC-Li 2LZ'IL .k1 ctci. 7. Permanent Address (&lZ12{t 2841 ) ^i?1121^vi[ 721 ^^21d1 2&^ YZ (34ci,(0i. Rzo-tl 2tZ,tlj £k1 ct%. -a ctci+i.ld Zit Kalil R41j vl rs I tl4 cli 4ict tact ° °kL' (as) b2cl. 8. Phone No. (b -t 4.) : &A:4LZl/Z414sizl-ii 4L-t -iWZ E2L'Lg' .
9. Mobile No . (2.ilc-Act 4.) : §1lZLl2l/z1M1218[l tl illWl6ct 4&t EkLictcil. 10. E-Mail ID (tS-it4Sc-t zt t) : h44lz1/^,[£th1Z1 tS-'t5c-t max EPtig4. 11. Subsribe's Bank Details (48 Wtdl-[l [gild) : 3il^il2l^zl[ti3lz1d1 WA [gOlcll E2Llgg1. 12. Value Added Service ((:q q1 u acti il) : SMS vi t E-Mail iLptgcu tltoq vzaz
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-
Section-B : Subscriber's Employment Details to be Filled and attested by DDO (&liztlzl/'t1k§lz1-l1'i1321t c. 1d1 [goLcll I I'K .&^1zt L ci.zgL-{l it I--AK z L) : 1. Date of Joining (.14(, dlzlvt) : &.L;.LZl/'tR&lzl-[l -iLR11-d ISLE dlzl"i £k1 ctc[l. 2. Date of Retirement
([-tci[ri-1a. ctiTh4) : .&2R LZ1/zi.[tlh1Z1-L1• 2iz^& LZ811-t1 RCLA1lt-L
[ iz{ it xlz 2lR[gd [1q[21-R dizl"t EsLL 1. 3. PPA No. (41.41.& 4&t%) : -idl g[ `d X'.ild 2lrKvtt zt-4.4 PPPF 9R1 eWWlc u i-u[ ztt4c--t PPA No. (Peemanent Pension Account No.) vi.zci. I dlc4 i 4lctlli.i b4 tlzlvil47l 34.Ld °(itL X114 E9 cl 9 ; yiL§Slil vlldl 7WZ 52Ug41
4.
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5. Office 6. Department 7. Ministry Subscriber Details
8. DDO Registration No.: DPPF DDO REG. NO. DPPF 9. DTO Registration No.: 10. Basic Salary 11. Pay Scale ➢
Section-C : Subscriber's Nomination Detail (Gtr C3d t1 ROLct) 1. Name of Nominee (Pt'jC3ct' -LLAt) : SALZUZ1/zi[ l lZ1 °G^t P-tj6ci. b . d'-t Y2 %L2 -t1Z. 4%Ki 4th a w[3^1i P L 9.009t41%Il ,l.
. ?OWL bt=t bqtdl xu1q C4 t t t1ttC1-tt (^loi-(l abLctlkl.-it UZgLtJit
2. Date of Birth (°o t ct1Z14) : Ptq3-ct 9Z41ALl vil4cl, cq6 2iall2 ts'Lrl ca d'-t1 °il-it ctt2k11t 6211441. C ; 1?&c1 at[ t-LL sA1211Z1/ziR§iZ1 UL4-'LL 3. Relationship with the Nominee (ZtW.tt) k j d ZLWt{ E.?U4°iL 4. Percentage Share (eacu21 3tAt11 [eZZlt) L ^t sci c Bct' llu4t-it Z-hLqL:^l RI-LL' [dZ2ll. q bi 3 s?xd q q cgE-dt k1kC1 ^.L4 ct4l B3^ L;-(L vti a-^14R1-i.1 ZLZti° i 9.00 9tcit 4%ZZ2l ld `c9.
5. Nominee ' s Guardian Details (Pt^.^ti. S2lgtc-l W.(-ct-tt 41Ctlr1 [gold.) : %l. P-tj§ct SZA' C-L cz&t ZL°1Z ^,Lq dit ct ^y2^wti ct-LL 4LCa-tl ['4z)lu 52U441 Zwqtdt 0. 6. Condition Rendering Nimination Invalids (21Zc1 Pt' &ct v1ALL-t 6Z2L) 2LZdil (-,tg6ct b&4Lt•'-1. gdt1 dLzt ct 2t%d c-LW 41.
➢
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Section-D : Subscriber's Scheme Details (^41-t-Q. R i(t) :
4&u.i. NSDL =t Ai'--Z
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9L4 -iitt : https://www.npsera.nsdl.co.in/state-forms.12hn https://www.npscra.nsdl.co.inldownloadlgovennent-sectorlstate-govemment/froms/Form-S 1 Application for-Allotment of PRAN.pdf.
G.C.P.G.-(V)-530-2,00,000-11-2011-(SIS-2)
Annexure S5 Covering letter for Subscriber Registration Application Forms (To be submitted by DDO in duplicate on official stationery) To NSDL CRA, From:
Date:
DDO Registration Number: DDO Name and designation: DDO's contact No.: (in words) number of Subscriber Enclosed please find registration application forms, for the purpose of allotment of Permanent Retirement Account Number (PRAN). I the authorized signatory, do hereby declare that what is stated above is correct and complete. Yours faithfully,
Signature/Name of authorized signatory Stamp of DDO
Acceptance Date and Stamp of FC branch
--- - - -------- - ------------- - - -- - - - - - - - - - - - - - - - - - - - - - - - Instructions: 1. This covering letter is to be provided by the DDO along with the subscriber registration forms. 2. The total number of forms per covering letter should not exceed 50. If the total subscriber registration forms exceed 50, kindly provide different covering letters. 3. Please quote the correct DDO Reg.No. allotted by CRA. The forms are liable to be rejected if incorrect DDO Reg. No. is mentioned. . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Page I
nnexure Sl
Application for Allotment of Permanent Retirement Account Number (PRAM (To avoid mistake(s), please follow the accompanying insnvctions and examples carefully before filling up the form)
To affix recent Coloured photograph (3.5 cm , 2.5 cm)
Acknowledgement No. (To be filled by FC) Permanent Retirement Account Number : (To be filled by FC after PRAN generation )
Sir/Madam, I hereby request that a permanent retirement account number be allotted to me. I give below necessary particulars : Signature/Left Thumb Impression of Subscriber in black ink
Section A - Subscribers Personal Details (* indicates Mandatory Field) 1. Full Name (Full expanded came: initials are not permitted) Sort. Please Tick as applicable, Shri ❑ First Name
❑
Kumari
❑
Middle Name Last Name
❑
2. Gender * Please Tick as applicable, Male
❑
Female
6. PAN
3. Date of Birth *
D D M M Y Y Y Y (Date of Birth to be Certified by DDO) 5. Father's Full Name: First Name Middle Name Last Name
6. Present Address: Flat/Unit No, Block no. Name of PremiseBuildin ill e Area/Locali /faluka District/Iown/Ci
State /Union Territo Coun
Pin Code e m-- n 7. Permanent Address: If same as above, Please Tick else, Flat/Unit No, Block no. *
1
Name of Premise/Building/Village Area/Locality/Taluka I Distric"'T i n/Ci
I
F- 7-7 1
I
1
I
1
State / Union Territo
I
I
I
1
1
1
Country *
Pin Code * I I S. Phone No. STD Code Phone No. 9.MobileNo.
1
1
1
P
Aunezure SI 10. Email ID
Pace
I I I 11. Subscribers Bank Details *: (Please refer instruction no. 4) Savings A/c ❑ Bank A/c Number
Curren A/c ❑
I
Bank Name
I
Bank Branch
I
Bank Address
IF4=4 1 1 1
I
I
1
Pin Code Bank IFS Code (If IFS code is not available, then provide MICR)
Bank MICR Code In the absence of IFSC as well as MICR, I hereby confum that: "The IFSC/NUCR is not available for the Bank-Branch mentioned above"
❑ [Please tick (1i) in case, IFSC and MICR are not available] ❑ Declaration by subscriber for Bank detail : At present, I do not have a Bank account. However, I confirm to provide the requisite Bank account deta il s within six months or on opening of Bank account whichever is earlier to the associated nodal office for updating the same in CRA system. (Please tick ('f) in case, Bank details are not available) 12. Value Added Services: i) SMS Alert Yes
❑
No
❑
ii) Email Alert: Yes
❑
No
❑
1 what is stated above is true to the best of my information & belief
, the applicant, do hereby declare that
Date : D D M M Y Y Y Y
Section B - Subscribers Employment Details to be filled and attested by DDO (Ail Details are Mandatory)
Signature/Left Thumb Im ression of Subscriber
1. Date of Joining 2. Date of Retirement D D M M Y Y Y Y D D M M Y Y Y Y 3.
PPAN
4. Group of the Employee (Please Tick) Group A ❑ 5. Office
6,
Group B
( Please refer
❑ Group C
❑
to instructions No.5.)
Group D ❑
ent
1 1
7. rvunis
I I
I
I
I
S. DDO Registration Number 9. DTO Registration Number I_n (Please refer to 10.
Basic
Salary
instructions
No.6.)
11. Pay Scale
Certified that the above declaration has been signed / thumb impressed before me by after he / she has read the entries / entries have been read over to him / her by me and got confirm, ed by him / her. Also certified that the date of birth and employmen t details is as per employee records available with the De sftmeut.
Signature of the Authorised Person Designation of the Authorised Person Date:
Robber Stam of the DD O
j ^^ Name of the DDO D D M M Y Y Y Y Minis try
Annexure SI Pass 3 Section C - Subscriber ' s Nomination Details (* Indicates mandatory Field for nominee) I. Name of the Nominee *
I st Nominee
2nd Nominee
3rd Nominee
First Name *
First Name
First Name
Middle Name
Middle Name
Middle Name
Last Name
Last Name
1 Last Name
2. Date of Birth (In case of a minor *: 1 st Nominee 2nd Nominee 3. Relationship with the Nominee*: 1st Nominee
3rd Nominee
2nd Nominee
3rd Nominee
I 4. Percents a Share Fl at Nominee 5. Nominee ' s Guardian Details ( in case of a minor)*: 1st Nominee ' s Guardian Details First Name
°/ 2nd Nominee
% 3rd Nominee
„`° 111100 a 'uaruran ueraus
I
3rd Nominee's Guardian Details ame*
Name
me Iffilmim m . Conditions rendering nomination invalid: 1st Nominee 2nd Nominee 3rd Nominee
Section D - Subscriber Scheme Details 1st Scheme Pension Fund Managers Name/Code
Scheme ID No./Name
Perc en
Sh are o/
Pension Fund Managers Name/Code
3rd Scheme Pension Fund Managers Name/Code
Scheme ID No./Name
Scheme ID No./Name
Percenta a Share
Percents Share o/
Section E - Declaration I understand that there would be PFRDA approved Terms and Conditions for Subscribers on the CRA website governing Pin (to access CRA /NPSCAN and view details) & T pin. I agree to be bound by the said terms and conditions and understand that CPA may, as approved by PFRDA, amend any of the services completely or partially without any new Declaration/Undertaking being signed.
T what is stated above is true to the best of my information R_ belief
, the applicant, do hereby declare that
Date :
D D M M Y Y Y Y Signamre/Left Thumb Impression of Subscriber
Annexure Si Pave
It
INSTRUCTIONS FOR FILLING FRAM FORM a) This form is to be used by State Governments /Union Territories/State Autonomous Bodies employees. b) Form to be filled legibly in BLOCK LETTERS and in BLACK INK only. c) Details Marked with (*) are the mandatory fields. d) Each box, wherever provided, should contain only one character (alphabet/number/punctuation mark) leaving a blank box after each word. e) 'Individual' Subscriber should affix a recent colour photograph (size 3.5 em x 2.5 cm) in the space provided on the form. The photograph should not be stapled or clipped to the form. (The clarity of image on PRAN card will depend on the 4,rslity and clarity of photograph affixed on the form.) f) Signature /Left thumb impression should only be within the box provided in the form. The signature should not be on the photograph. If there is any mark on the photograph such that it binders the clear visibility of the face of the Subscriber, the application will not be accepted. g) Thumb impression , if used, should be attested by a Magistrate or a Notary Public or a Gazetted Officer under official seal and stamp. Sr. No.
Item No
Item Details
Guidelines for Filling the Form Section A - Subscribers Personal De
1
3.
Date of Birth
2
6.
Present Address
3
8, 9, 10
Phone No., Mobile No, & Email ID
All Dates Should be in' DMMPPYY"Format All future communications will be sent to present address.
It is advisable to mention either "Telephone number" or "Mobile number" or "Email id" so that Subscriber can be ' tatted in future for any discre ancy. For subscribers, the Bank detl'is are mandatory. In case, Bank details are not available at the time of filling the form, subscriber has to accept the declaration for providing the Bank details within six months or on opening of Bank account whichever is earlier. The subscriber has to provide IFS Code. If IFS code is not Subscriber's Bank 4 11 available, MICR code can be provided. If both, IFSC as well as MICR is not Details available, the subscriber has to Accept the declaration - "The IFS/MICR is not available for the Beak-Braneir mentioned above " by ticking in the adjacent box. Subscriber shall provide a cancelled cheque, the details of which should match with the details rovided. Section B - Subscribers Em plo yment ' It is mandatory to fill the Subscriber's Employment details in the application. The employm details should be filled by the respective DDO of the Subscriber and should be verified by the Authorised Signatory , DDO should rati Overwriting / Stri in off of an of the em to ant details. Kindly provide the PPAN (Permanent Pension Account Number) or equivalent number, if it has been allotted to the subscriber by the respective state government / Union Territo / State Auton us Bo .
5
3.
PPAN
6
8&9
DTO Reg. No. & DDO Reg. No.
7
4.
g
5.
DTO Reg. No. and DDO Reg. No. is the unique Registration number allotted by Central Recordkeeping Agency.
Section C - Subscriber' s Nomination Subscriber can nominate of three nominees. Subscriber can not fill the same nominee details more than once. Percentage share value for all the nominees must be integer. Fractional value will not Percentage Share be accepted. Sum of percentage share across all the nominees must be equal to 100. If sum of percentage is not e qual to 100, tire nomination will be rejected Nominee's Guardian If a nominee is a minor, then nominee's guardian details will be mandatory. Details Section D - Subscriber scheme de tails
If the S ubscriber is unable to mention the Scheme details i.e. PFM Name, Scheme Name .£ Percentage Allocati on h e can contact the nearest Facilitation Centre (FC) for information or the Subscriber can also search for the schemed on h : //w scra.nsd co.i Subscriber can select maximum three schemes. Details of 'schemes are available on fww
9
Scheme
me scheme details more than once. If a scheme time is filled in the form for scheme setup there must be a PFM name and percentage contribution
filled for that scheme.
10
If the Scheme details are not filled' default scheme as a ro d by PFRDA will be a licable . Scheme Contribution Value will be in terms of percentage. Ibcannot be in terms of amount . Percentage Share Percentage contribution value for all the schemes must be integer. Fractional value will not be accepted . If the sum of contributions (in percentage) across all the schemes is not equal to 100 , the balance will be allotted to the default scheme a roved b PFRDA.
GENERAL INFORMATION FOR PRAN SUBSCRIBERS a) Subscribers can obtain the application fom for PRAN in the format prescribed by PFRDA ('Pension Fund Regulatory & Development Authority) from DDO or can freely download from the CRA website ( htto •//www nose sdl co in ). b) The request for a reprint of PRAN Bard with the same PRAN details or/and changes or correction in PRAN data can be made by filling up 'Request for change/correction in subscriber master details and /or re-issue of l-PinJt-Pin/PRAN card' or/sad 'Request For change in signature and/or change in photograph '. The form is available from the sources mentioned in (a) above. c) The Subscriber can obtain the status of his/her application from the CRA vvebsite or through the respective DTO. d) For more information Visit us at bSn•/hnvw nose dl co'n Call us at 022-24994200 e-mail us at info crafaus Lco in Write to, Central Recordkeeping Agency, National Securities Depository Limited, 4th Floor. `A";Ming, Trade World, Kamala Mills (W), Mumbai - 400 Oli.
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