Annexure – Additional Details For Withdrawal

1. PRAN*

2. Full Name*
First Middle Last
4. Marital Status* Married  Unmarried/Others 
Maiden Name (in case of female married subscriber)

5. Spouse's Name (only if subscriber is married) First Middle Last

6. Spouse Gender (only if subscriber is married) Male  Female 
7. Spouse PAN
8. Spouse Date of Birth
DD / MM / YYYY
10. PAN*

11. CKYC Number

12. Are you a Politically Exposed Person (PEP)* Yes  No 

13. Are you related to a Politically Exposed Person (PEP)* Yes  No 
Do you have any history of conviction under any criminal proceedings in India Yes  No 
or abroad?
If Yes, please provide details
14. Contact details Alternate phone number :
16. Nomination Details: If any of the nominee is Minor
Guardian Date of Birth (Only in case of minor) :
Guardian Signature (Only in case of minor):

Guardian Date of Birth (Only in case of minor) :

Guardian Signature (Only in case of minor):

Guardian Date of Birth (Only in case of minor) :

Guardian Signature (Only in case of minor):
Subscriber's Family Member Details* (To be filled in case subscriber has selected Joint Life Policy or NPS-Family Income option)
Family member Details for providing annuity as chosen by the Subscriber.

Sr.No Details Name Aadhar/VID PAN$ Date of Birth

1. Spouse$
DD / MM / YYYY
2. Dependent Mother (if living)
DD / MM / YYYY
3. Dependent Father (if living)
DD / MM / YYYY
4. Child 1(if living)
DD / MM / YYYY
5. Child 2(if living)
DD / MM / YYYY
6. Child 3(if living)
DD / MM / YYYY
Note: In case of children being more than 3, please specify in an additional sheet.
Fields marked with* are mandatory.
$Mandatory in case subscriber opts for Joint Life Policy. & NPS- Family Income Option.

Declaration by the Subscriber

I hereby declare and state that all the details provided in the form above are true and correct to the best of my knowledge. I also agree that NPS Trust / CRA shall not be held
responsible/liable for any losses that may arise due to incorrect bank account details provided by me. Further, I authorize the National Pension System Trust (NPST)/ CRA to share
information pertaining to my withdrawal application with the Annuity Service Providers for arranging the purchase of annuity as is mandatory under NPS.

Date : DD/MM/YYYY * Signature/Thumb Impression of the Subscriber

*In case of female right thumb Impression and in case of male left thumb Impression may be taken.
Subscriber's Annuity Details - (Not to be filled in case of complete withdrawal)

Select Annuity Frequency: Please tick one of the below options as per your choice. (For Government Subscriber, annuity frequency is monthly only)

 Monthly Quarterly  Half Yearly  Annual

Declaration by the Proposer: (Not to be filled in case of complete withdrawal)

I hereby declare that the foregoing statements and information’s have been given by me after fully understanding the questions and the annuity options and the same are true, accurate
and complete in every manner and respects and that I have not withheld or omitted to give any material information. I understand and agree that the statements in this proposal
constitute warranties. I do hereby agree and declare that these statements and this declaration shall be the basis of the contract of assurance between me and Annuity Service Provider
(Company) and that if there be any misstatement or suppression of material information or if any untrue statement is contained therein or in case of fraud by me, which comes to the
knowledge of the company at any future point of time, the said contract shall be treated as per provisions of Section 45 of the Insurance Act 1938 or any other applicable provisions as
amended from time to time.
I also understand and agree that the company shall additionally levy or recover all the applicable taxes like service tax, surcharges, cess etc. from the premium which are necessitated
by various enactments of central and/or state legislatures from time to time.
I understand that the contract will be governed by the provisions of the Insurance Act 1938, and other applicable laws in India and that the contract will not commence until a written
acceptance of this proposal is issued by the company and that the benefits under the policy shall be subject to the terms and conditions contained in the contract. I also agree that the
amount held in proposal/policy deposit shall not earn any interest.
I further states that the product features and terms and conditions of the policy have been thoroughly explained to me and having understood, I consent to the same.
I further understand that final Annuity amount would be subject to the actual corpus value to be utilized for the purchase of annuity at the time of its issuance.
I also acknowledge and agree that the funds will not be returned to me in case I choose to cancel the policy under free look period. These funds will be payable by company directly to
any other annuity scheme chosen by me which is authorized and approved under the prevalent regulations and applicable rules. Further, no interest will be payable to me on the funds
held during this transition period.
I hereby authorize company to send information and servicing related communication regarding this proposal or resulting policy through Email/SMS/Phone Call.
I hereby authorize the company to provide me/our details to banks, financial institutions and third party service providers that the company may have tie-ups with, for verification of
proposal details and for servicing of policies.

Signature of the witness Signature / Left thumb Impression of the Proposer

Affix a recent self signed
photograph
Name and Address of witness:

Date: DD / MM / YYYY

Declaration when Proposal form is filled by person other than proposer/proposer signs in a vernacular language/proposer is illiterate (Not to be filled in case of
complete withdrawal)
I hereby state that I have read out and explained the contents of this proposal form and all other relevant documents to the I/We state that the product details, contents of this form and
proposer in _____________________________________________________language that he/she/they have understood relevant documents have been fully explained to me/us and
the same and agree to abide by the terms and conditions of the resulting policy and have affixed his/her/their that I/We have fully understood them. I/We certify that the
replies in the proposal form have been recorded as per the
signature/thumb impression on the proposal form in my presence.
information provided by me/us.

Signature of the person making the declaration

Name & Address __________________________________________________________________________________

Signature / Left thumb Impression of the Proposer
________________________________________________________________________________________________

Place ______________ Date: DD / MM / YYYY

Declaration & Attestation by Nodal Office
TO BE FILLED/ATTESTED BY DDO/PAO/POP-SP
1. I/we have verified the documents as submitted by the Subscriber with the originals and authorized this application for processing of the subject claim of the subscriber. It is certified tha
the details as provided in this application form are matching with the information available in the official record maintained by us. The complete information provided in this form including
declaration and nomination details have been provided by the Subscribe
Sh/Smt/Ms __________________________________________ after he / she having read the entries / entries have been read over to him / her by me and got confirmed by him / her
2. That all the contributions with respect to the Subscriber's NPS contribution and employer contribution have been transferred in to the PRAN of the subscriber and no further contributions
are pending at Nodal Officer level. (only for government nodal office)
3. That Identity of the Subscriber is certified as provided in the withdrawal form above. The name of Subscriber as mentioned on the withdrawal form has been verified and can be accepted
as final.
4. It is certified that the bank account (Salary Account) details provided in the form is as per the salary records maintained in our office. the bank account details (salary account) of
subscriber's as provided in bank details section have been checked and verified in the same can be excepted for payment.(only for government nodal office).
5. We hereby certify that subscriber has been discharge from the services of the concerned office on account of invalidation or disability (in case of government subscriber). We here by
certify that we have checked disability certificate issued by government surgeon or doctor stating the nature and extent of disability (in case of non-government subscriber)[applicable in
case of withdrawal due to incapacitation only]

Rubber Stamp of the DDO/POP-SP/NLCC Signature of the Authorized Person

DDO/POP-SP/NICC Registration Number __________________________

Designation of the Authorized Person : _________________________ DDO/POP-SP/NICC Office Name:_________________________ Date:_____________________

Rubber Stamp of the DTO/PAO/POP/Aggregator Signature of the Authorized Person

DTO/PAO/POP/ Aggregator Registration Number ___________________

Designation of the Authorized Person : __________________________ DTO/PAO/POP/ Aggregator Office Name:_____________________

Date:___________________