NATIONAL PENSION SYSTEM (eNPS) - SUBSCRIBER REGISTRATION F09/4

SUBSCRIBER REGISTRATION FORM

AarWear based registration Non Aadiwar based resist' a ion I ur
Please Select your Cater). All Citizen Model Corporate Sector
. ROL ereovernance LIMY CamNter
Select your Central wen!keeping Allem), (CPA) infrestruture Ltd s/ Inf rastrutUre Ltd
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 :

KYC Number
Retirement Advisor Code

1, PERSONAL DETAILS:
Name of Applicant In lull Slid WI smtI 1 Kumerli 1
First Name ' FICATHAMESH
Middle Name HARISHKUMAR
Last Name MODEM
Maiden Name (ff ant)
Father's Name HARISHKUMAR RATILAL MODHA
Mothers Name' DEV5MITA HARISHKUMAR MODEM
Date of Eldh ' 72 1. / 0 7 / 91916
City of Birth • PORBANDAR
Country of Birth INDIA

Marital Statue Married Unmarried Others Gender ' yf Male Female Others

Nationality* IN-Indian

Spouse Name'
Residential Statue Indian

2 PROOF OF IDENTRY(PolE
Passport spry Date
PaseP011
Voter ID card PAN Card FILPM670IF
Driving License Driving LIcensa expiry Date
UID (Aarthaar) NREGA JOB Card
Others
3, PROOF OF ADDRESS (PoA)
Proof &Address Passport vi Driving License Aadha r card Voter ID card (VEGA Job Card I Ration card .1 Others [
Registered Lease Sale agreement of residence
Latest Gas BM Electricity Bill TelephoneRandline) BM

4.1 CORRESPONDENCE ADDRESS DETAILS'

Address Type Residential/Business I Residential Business Registered it/ Unspecified

FIN/Room/Door/Block no 151 FLOOR, MUTUAL COMPLEX 1

Landmark NEAR SALES INDIA SHOWROOM

Premisea/SuildingNillage INCOME TAG

Road/Street/Lana

Areatocality/Taluka IAHMEDABAD

City/TOwnfiDistrlat AHMEDABAD PIN Code 380009

SteD/U.T, GUJARAT

Country INDIA

0.2 PERMANENT ADDRESS DETAILS: 111 Tick ( ) In the box in case the address is same as above.
Address Type' Residential/Business V Residential I I Business I Registered Unspecified
Flat/Room/Door/Block no. TRIPADA t GAYATRI SOCIETY

Landmark BEHIND PATEL OIL MILL

Pramises/Bulleing/ KADIYA PLOT

RoadReeetilane

Areatocelity/Taluka PORBANDAR

CIty/Town1131stric1 POR8ANDAR PIN Code 360575

SINGU.T. GUJARAT
Country INDIA

R CONTACT DETAILS
Tel. (011) 8866076695 Tel. (Res) : 91333860910

Mobile y 91 9723736767
Ematl ID MODHA2107GGMAIL . COM
 6. OTHER DETAILS
Occupation Details

Private Sector E Government Public Sector D Self Employed ID Professional El Agriculture 0

Homemaker Student 0 Others-Retired 0 Other (Please siseclry)
Income Range (per annum) Upto 1 lac 0 I Ds to 5 lac 0 5 lac to 10 D lOFao to2Slac D 25 lac and above E
Educational Duktications Below SSC 0 SSC0 MSC 0 Graduate Masters 0 Professionals (CA. CS, CMA, etc.)
Please Tick ff Applicable Polikally exposed D Related to Politically exposed 0

7.SUBSCRIBER BANK DETAILS:

Account Type Savings ADD Current AD 0

Bank No Number 2201156008001499
Bank Nark' THE KARUR VYSYA BANK
Branch Name AHMEDABAD
Branch Address PLOT 503 504 1 SARNI VII) B BLOCK NEHRU BRIDGE CORNER, ASHRAM ROAD, AHMEDABAD 380089
Pin Code 3815009

State/UX. GUJARAT
Country INDIA
Bank MICR 380053002 IFS code KVBL0002201

H.SUBSCRIBER NOMINATION DETAILS'

Name of the Nominee You can nominate up to a maximum of 3 nominees and if you desire so please fill in Annexure ill (Additional NomInation Pone)
provided separately)
Name of the Heroines provided
Nominee Name OHYATA HARISKUR MODHA
Relationship with the Nominee SISTER

Date of Birth (In case of Minor) 1 0 / 0 5 / 1 9

Nominees Guardian Details (In case of a minor)
Nominee's Guardian

NPS OPTION DETAILS(Please tick (l as applicable).

I would like to subscrIbe for Tier II Account also YES NO If yes, please submit details In Annexure I

PENSION FUND (PF) SELECTION AND INVESTMENT OPTION'

(I) PENSION FUND SELECHON (Tier I): Please read below conditions before opting for the choice of Pension Funds:
All Citizen Model: Subscribers Under All CitUen model has the op ion to Moose one of The a Stable PFs as per their choice in the table below.
Corporate Model: Subscribers shall have the option to choose one of the available PFs as per the below table In consolation with their respective Employer.

Name of the Pension Fund PFM Selected

LIG Pension Fund Limited

SBI Pension Funds Private Limited I

UTI Retirement Solutions Limited
ICICI Prudential Pension Funds Management Company Limited

Kotak Mahlndra Pension Fund Limited I I

Reliance Capital Pension Fund Limited

HDFC Pension Management Company Limited P 1

BIRLA Sun Life Pension Management United

' Selection of Pension Fund D mandatory both in Active and Auto Choice. In rase. you do net indicate a choice of PE, please note that It is deemed that you have
consented forthe default PF specified by PERO& Currently, SBI Pensio Funds Private Limited is I e default PF.
DI INVESTMENT OPTION (Available for All Citizen Model and Corporate Model Subscribers)
ACtive Choice Auto Choice
For details on Auto Choice, please refer to the Offer Document. Please note:
1.1n case you select Active choice fill up section III below and if you select Auto Choice NI up section IV below.
2.In case you do not indicate any Investment option, your funds Mil be invested in Auto Choice (LC 50).
3. In case you have opted for Auto Choice and 511 up section III below relating to Asset Allocation,
the Asset Allocation Instructions will be ignored and Investment will be made as per AutaChoice.
 gig Asset Allocat n (to be filled up only In case you h ve selected the 'Active Choice investment option)

Asset Class E c G A Total

(Cannot exceed 75%) (Was up to 100%) (Max up to 100%) (Max up to 100%)

%share 70 15 10 5 AO%

Please note:
Upto 50 years f age, the maximum permitted Equity Investment. is 75% of he total asset allocetin .
From 51 years arid above, maximum permitted Equity Investment will be as per the equity allocati n matrix provided In Annexure A. The tapering off of equity
allocation will be carried out as per he matrix on dale of birth.
The total alloc Ion across E. C and G asset classes must be equal to 100%. In case, the allocatio is left blank andfor does not equal 100%, the applkation shall
be rejected.
Asset class E- Equity and related instruments; Asset darts C- Corporate debt and related instrum nts; Asset class G- Government Bonds and related
Instruments; Asset Class A-Mtemative Investment Funds including Instruments like CMI3S,MBS,REITS.A1Fs JEW% etc.

(lv)Auto Choice Option go be filled up only In case you have selected the Auto choice' investment option). In case, you do not indicate a choice of LC.
your funds will be Invested ae per C 50.
Life Cycle (LC)Funds Please tick

LC 75 Mae:-
1. LE 75-ills the Ere cycle fund where the cap to Emaylnyestmanfis is %% Gibe rad asset
2.watt nista Lire cycle fund *heft Lhe Gap to Emily Inv-ww. fs is MY of me wird asset
LC 50 3. LC 25-it Wale LIR cycle rural where OleGapto EquilyInvestmants Is Meths total asset
LC 25

11. DECLARATION BY SUBSCRIBER*

Declaration &Autherzetlon by all subscribers

I have read and understood he tears and conditions of the National Pension System and hereby agree to the same along with the PFROA Act, regulations
framed there under end declare that the Information end documents furnished by me are true and correct to the best of my knowledge and ballet I undertake
to Inform Immediately the Central Record Keeping Agency/Netionel 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 !DOD 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
pFROA. whether complete r peel& 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 webeite and view details) &T-PIN.

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 dght to
close my PRAN In case I em found violating the provisions of any law relati g to prevention of monad laundering.

Date El
7 @ 1 5 17 1 2 1 e 1 1 F
Rape:
f- H.roodka,
iiilifieddiumt
Szgnakire/Thumb lnipressiorr of Subscnber In black ink
r L11 In case of male and RTI In case of female/
12. DECLARATION ON FATC111(Foreign Account Tax Compliance Act) COMPLIANCE:
Section r
US Person YES NO ,/

Document Evidencing Citizenship YES NO

Reason for No evidence

Section IF I
For the purposes of taxa On, I am a resident in the to' owing counties and my Tax Man neaten Number (TINMfunctional equivalent In each oountj is Set I
out below or I have Indicated that a TIN/functional equNalent le unavailable (kindly fill details of all countries of tax residence If more than one):

Counby/onunhies of Address In Me Tax Identification Number TIN/ Functional equivalent Validity of documentary
tax residency jurisdiction (1111)/Functienal equivalent Number Issuing Country evidence provided
for Tax Residence Number

INDIA AHMEDABAD F3LPM6701F INDIA 17/02/2022

AHMEDABAD GUJARAT
380009
I certify that:
It ahall be my responsibility to educate myself and to comply at all times with all relevant laws relating to reporting under section 2855A of the Act read
wilfi the Rubs 114F to 114H of the Income tax Rules, 1962 thereunder and the infomiatIon provided in the Forrn Is In accordance with the aforesaid rules,
the Information proOded by me In the Form, its supporting Annexures es well as In the documentary evidence are, to the best of my knowledge and beast true.
correct and complete and that I have not withheld any material information that may affect the assessmengcateg odzation of the account as a Reportable account
or otherwise.
C) I permithuthorise the NPS Trust to collect, store. communicate and process Information relating to the Account and all transactions therein, by the NPS Trust
and
any of NPS intermediaries wherever situated Including snaring. transfer and disclosure between them and to the authorities in andlor outside India of any
di I undertake the responsibility to declare and disclose within 30 days from the date of change, any changes that may take place In the Intonation provided In the
Form, its supporting Annexures as well as in the documentary evidence provided by me or If any certification becomes Incorrect and to provide fresh
self-certification along with documentary evidence,
ri) I also agree that in case Of my failure to diedOse any material fact known to me, now or In future, the NPS Trust may report to any regulator and/or any authority
designated by the Government of India (GUI) rRBUIRDNPFRDA for the purpose or take any other action as may be deemed appropriate by the NPS Trust If the
deficiency Is not remedied by me within the stipulated period.
f) I hereby accept and acknowledge that the NPS Trust shall have the right and authority to carry out investigations from the Information available in public domain
for confirming the information provided by me to the NPS Trust
0) I also agree to furnish such infomiation andfor documents as the NIPS Trust may require from time to time on account of any change In law either in India or
abroad in the subject matter herein.
h) I shall Indemnify NPS Trust for any loss that may arise to the NPS Trust on account of providing incorrect or incomplete information.

Date 0 O s

Piece MerstOkeark
r rfludly,L
Signature/Thumb Impression ofSubscriber In black Ink
Name of subscriber": PRATHAMESH HARISHWMAR MODHA r LT In case of male and RTI In case of female)
13. TO BE FILLED BY POP-SP
Receipt No. el 7 digits)

POP-SP Registration Number

KYC Compliance Yes No

Document accepted for date of Birth Proof

Copy of PAN card submitted Yes No

Document Received: (Originals VedfIed) Self Corned (Attested) True Copies:

Identity Verification: Done

Existing Bank Customer:

I/we hereby certIfy/confirm that Stri/Srnt/Kum Is an existing customer of the Bank having fully operative Saving Sank account
no at branch and
KYC norms required for opening Bank Account which match the requirements for opening WS account have been fully complied with. We further confirm that the S.
B. arc of Sho/SmtiKum
Is not e Basic Savings Bank Deposa Account' .
Adhaar Based KYC Certificate:
I/we hereby certify that Aadhaar Number of Sh/Smt/Kum .. has been Checked and he name and address
mentioned on the original Aadhaar card
are matching with that mentioned on BPS application form

To be filled by POP-SP
Name:
Designation:

Place:

POP-SP Seal Signature of Authorized Signatory Date:

[To be filled by CRA - Facilitation Centre (CRA-FC)]

Received by CRA-FC Registration Number

Received at Oat :

Acimmededgement Number Gy CRA-HC) 11851631

FRAN Alloted 11010539500

ACKNOWLEDGEMENT
Name of the Subscriber PRATHAMESH HAKISHKUMAR ROMA

ConelbutIon Amount Remitted: Z 500.00

Data

Stamp and Signature of the EalplOyePoP: