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1673432649950APY T4jccR7F

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45 views2 pages

1673432649950APY T4jccR7F

Uploaded by

dhiraaz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ATAL PENSION YOJANA (APY) - SUBSCRIBER REGISTRATION FORM

(Administered by Pension Fund Regulatory and Development Authority)

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:
* Indicates mandatory fields. Please fill the form in English and BLOCK letters
1. BANK DETAILS:
Bank A/c Number* 00000031056339753
Bank Name* STATE BANK OF INDIA Bank Branch* TANGLA

2. PERSONAL DETAILS:
Title SHRI First Name* DHIRAJ
Middle Name Last Name SAIKIA
Date of Birth* 02/08/1993 Age 29
Mobile Number* 8133918106 AADHAAR
Email ID [email protected] Married NO
Name of Spouse Spouse AADHAAR
Nominee's Name* GEETANJALI TALUKDAR Nominee AADHAAR
Additional Details in case nominee is a Minor
Relationship with the subscriber* MOTHER
Nominee's Date of Birth* 24/01/1966
Guardian's Name
Whether beneficiary of other social security schemes NO
Whether Income Tax Payer NO

3. PENSION DETAILS:
Pension Amount* 1000 2000 3000 4000 5000

I hereby authorize the bank to debit my above mentioned bank


Contribution Amount account till the age of 60 for making payment under APY as
( Monthly ) + applicable based on my age and the Pension Amount selected by
529.00
(in Rs.) me. If the transaction is delayed or not effected at all for insufficient
(To be filled by the Bank) balance, I would not hold the bank responsible. I also under take to
deposit the additional amount together with penalty thereon.

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. Further, I do not hold any
pre-existing account under APY. 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.
I hereby authorize PFRDA to use my Aadhaar details for APY and authenticate my identity through the Aadhaar Authentication system in
accordance with the provisions of the Aadhaar (Targetted Delivery of Financial and other subsidies, Benefits and Services) Act, 2016 and
rules and regulations notified thereunder. I have been given to understand that my information submitted to PFRDA herewith shall not be
used for any other purpose other than mentioned above, or as per requirement of law.

Date 11/01/2023 Signature/Thumb Impression* of


Subscriber
Place TANGLA (* LTI in case of male and RTI in
case of female)
ACKNOWLEDGEMENT - SUBSCRIBER REGISTRATION FOR ATAL PENSION YOJANA (APY)
(To be filled by the Bank)

Name of the Subscriber: DHIRAJ SAIKIA


PRAN Number: 500791613365
Guaranteed Pension Amount: 5000.00
Periodicity of Contribution: MONTHLY
Monthly Contribution Amount under APY (in Rs.) : 529.00
Name of the Bank: STATE BANK OF INDIA
Bank Branch: TANGLA
Receiving Officer's Name:
Date of Receipt of Application: 11/01/2023 Stamp and Signature of the Bank
**This is a computer generated form and does not require signature of the Branch Manager

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