Ver 1 1 Annexure -52

NAT~ONAL PENS~ON SYSTEM (NPS)

KFin Techno~ogies Private Limited
Request For Chanqe/Correclion ~n Subscriber Master detaNs And/Or Reissueof PRAN Card
[ To sneer matnke(sl rArase read the accompanyrna instruct one carefuty h fore fliNg p he form

For POP-SP/DDOINL-CC use: For POPIPOP-SPIPAOIDTO1DTAIPrAOI NL-AO/NL-OO use:

Registration No, .. Registration No:
Date of Receipt: . Date of Receipt: ... POP/POP-SPIPAO/DTO/DTNPrAO,’NL-AO/
NL-OO Stamp:

Signature and Stamp of POP-SPIDDOINL-CC Entered By:. Date......

Verified By’ Date:

Receipt No,: (Mandatory for POP/POP-SN . . .

Acknowledgement No.
iTo be tiled by Nodal OTce ao performed by CPA oystem~
I hereby request for the following details for the change ( Please tick ). [In case of change/correction in employment defarls, please contact your employer/Nodal Ofrice.]
A> Change or Correction in Subscriber Master Details \~—‘~ B) Reissue of PRAN Card
C) Employment Details
Permanent Retirement Account Number 0. ~ 0 0 0 00 ,~ ~ 4 ~) 3’
I hereby submit the following details of change. [Please tick (~) the box on left margin of appropriate row where change/correction is required and provide the details in the
corresponding rows.]

Section A Change or Correction in Subscriber Master Details (0 indicates Mandatory Field)

r i. PERSONAL DETAILS: (Please refer to Sr. No.1 of tire instructions)
Name of Applicant in full Shri Smt. Kumari
First Name0
Middle Name
Last Name
Subscribers Maiden Name
Fathers Full Name:
First Name
Middle Name
Last Name
Mother’s Full Name:
First Name
Middle Name
Last Name
Date of Birth /
(Date of Eteth should be suoponod by relevant documerrtery proof. Nodal O’Sce shall verify the same before updehng details in the CRA system.)
WoLtIcI you like to re-issue FRAN card in case of change in details pertaining to Subscriber’s Name, Yes No
Father’s/Mother’s Name or Date of Birth (This will be charged to Subscriber/employer by CR/1):
Gender Male Female Others
Marital Status Married Unmarried Others
Spouse Name
fRef,.,r Sr lb i of tnsfcsetroisl
CKYC Number Genorsted from Certrai NYC riea’sfi’y. Subm’ssion of poet forth0 serves necesesry.
Retirement Adviser Code
NYC Number, Retirement Adviser Code and Spouse Nsme fields are not appticeble for Government & NPS Cite Subscribers

I . 2. PROOF OF IDENTITY (P01) (Any one of the documents need to be provided along wtth the identdication number)

Passport Passport Expiry Datel

Voter iD Card PAN Card
Driving License Driving License Expiry Date
NREGA JOB Card
Others Name of the ID Pl.~as” r,,tar Sr t’fo. 2 of the trstrer.f eros.

UID (Aadhaar)
thereby authorize CRC rapistered ,Wtf, Pens’onF.,’icf Reqtifo tory and Ocvclop’nerif Cuth,~rify (PPROA) to use’ ny Aadnaai dotairs for National F ensies Sys fern (NPS and aufhrnfic.nfe r.iy ide’nity
threugfr the A~etfraarAt,ffientreat’oif sysfer,r fAcrdfraar bitserl e’-KYC services or fit OAf) in serorelan’ce with ftc rhih5i5e’55 si flu,’ Aadur,ror (Thrge’fed Oa:i~’rry orF.iraooiai u,’d otter S,’f,sre.ir.
CanoNs and Sr’roicos~ Act. 20 ff3 ass the allied r iNs ape reputations ‘fafrfied lfieraueder f .indurstand that the Aadhaar Nsfails fphysrcol and ‘or drg,taf. as the case mayba) submitted for auaifacg
sor,’icl’i, under NRC ml he marrfaieed [‘PS till fly err’,’ flu,’ e500unt 5 not inactive in NPS or the foneframe fferctdad by f5FRDA, the rigufetor s/NRA. wfscitea,’r ufatne f sr’dcrcnfand trial
Security dod conbdentatity of personal dvnfay Pta orsv,dcd, far his papas” cf ‘faer,uar based a.rfl,cnfAaf,o’i c ncrsu’vd by CR/h rag’ufs’’d wrf’i PiNto/h to’ such tine if is a,cfisbt as Orbit for
my Nt’S Srccciahi

KCRAQ.42-1 .1 I 0(7 ~fOF~ NTECH

‘Jar 1.1 Annexure S2 -

E] 3. PROOF OF ADDRESS (P0A) Correspondence Address Permanent Address

Please tick (V). as applicable] Passport/Driving License/U ID (Aadhaar)Noter ID cardl Passport Ioriving IJoense/UID (Aadhaar)Noier ID card!
# Not more than 3 months old. NREGA Job Card/Ration Card/Others NREGA Job Card/Ration Card/Others
Please refer Sr No. 2 of the instructions Registered Lease/Sale agreement of residence Registered Lease/Sale agreement of residence
#Latest Gas!Electricity)Tetephone[Landline] Bili #Latest GasiElectrieityiTelephone[Landlinoj Bill
El 4.1 CORRESPONDENCE ADDRESS DETAILS

Address Type* Residential/Business Residential Business Registered Office Unspecified

Flat/Room/Door/Block no Landmark
Premises/BuildingNillage
Road/Street/Lane
Area/Locality/Taluk
City/Town/District PIN Code
State/UT.

4.2 PERMANENT ADDRESS DETAILS ~ [Tick (V’) in the box in case the address is same as above.]
Address Type* Residential/Business Residential Business Registered Office Unspecified
Flat/Room/Door/Block no. Landmark
Premises/BuildingNillage
Road/Street/Lane
Area/Locality/Taluk
City/Town/District PIN Code
State/UT.

f3 5. CONTACT DETAILS
Tel. (OF)(with STD code) + Tel. (Res) )with STO code) +

Mobile + 9 1 (Mobile Number is required for communication and to get SMS alerts)
Email ID
Value Added Service i) SMS Alert Yes No ii) Email Alert: Yes No

Fl 6. OTHER DETAILS (Please refer to Sr no. 3 of the instructions)

Occupation Details [ please tick(v’)]
Private Sector Public Sector Government Sector Professional
Self Employed Homemaker Student Others (Please Specify)
~ Income Range (per annum) Upto 1 lao 1 lacto Slac 5 lao to 10 ac 10 lao to 25 lao 25 lao and above
~ Educational Qualifications Below SSC SSC HSC Graduate Masters Professionals ( CA, CS. CMA, etc.)
‘ Please Tick If Applicable Politically exposed person Related to Politically exposed Person (Please refer instruction no.3)

[1 7. SUBSCRIBER BANK DETAILS (Please refer to Sr no.4 of the instructions) [All bank details are mandatory except MICR Code.
You want to change Bank details of: Tier I ~.- Tier U
(In case you want to change bank details in both Tier I & Tier II Account, tick both check box)

Tier I Account : Savings A/c L—~’ Current Nc

Bank A/c Number 1 ~ 0 9 ~..g t
BankName ~
Branch Name ~ J-~ O~ ‘~LL~ ~
Q~-~ ~-i
?1~ ~ C !~ Fi~~ i;:. .,-~ ~7 ‘~ ~ V~
~UQ~SM~LU
Bank MICR Code £ 0 ~ O ~
~ IFS Code ~ 0 0
Tier II Account: If same as above for Tier I Yes else,
Savings Nc Current A/c
Bank A/c Number
Bank Name
Branch Name
Branch Address PIN Code
Verl.1 Annexure S2 -

Fl 8. SUBSCRIBERS NOMINATION DETAILS (Please refer to Sr No. 5 of the instructions)

I want to change Nomination details of: Tier I Tier II
(In case you want to change nomination details in both Tier I 8 Tier II Account tick both check box)
Tier I Account:
Name of the Nominee (You can nomnate up to a maximum of 3 nominees and it you desire so please fill in Additional Nomination Form provided on page no. 5 & 6 separately.)
First Name Middle Name Last Name

Relationship with the Nominee Date of Birth (In case of Minor) /

Nominees Guardian Details (in case of a minor)
First Name Middle Name Last Name
I I ~ 1.~~

Tier II Account : If same as above for Tier IYes - .1 else,

Name of the Nominee (You can nominate up to a maximum of 3 nominees and if you desire so please fill Additional Nomination Form provided on pages 5 & S separately)
First Name Middle Name Last Name

Relationship with the Norriinee Date of Birth (In case of Minor)

Nominee’s Guardian Details (in case of a minor)
First Name Middle Name Last Name

IX) 9. DECLARATION ON FATCA (Foreign Account Tax Compliance Act> COMPLIANCE (Please refer to Sr no. 6 of the instruclions):
Section 1*
US Person* Yes No F’
Section 11*
For the purposes of taxation. I am a resident in the following countries and my Tax Identification Number (TIN)ifunctional equivalent in each country is set
out below or I have indicated that a TIN/functional equivalent is unavailable (kindly fill details of all countries of tax residence if more than one):

Particulars Country (1) Country (2) Country (3)

Country/countries of tax residency
Address Line 1
City/Town/Village
Address in the jurisdiction for Tax Residence
State
ZIP/Post Code
Tax Identification Number (TIN)/Functional equivalent Number
TIN/ Functional equivalent Number Issuing Country
Validity of documentary evidence provided (Wherever applicable)
“I certify that:
a) It shall be my responsibility to educate myself and to comply at all times with all relevant laws relating to reporting under section 285BA of the Act read with
the Rules 1 14F to 1 14H of the Income tax Rules 1962 thereunder and the information provided in the Form is in accordance with the aforesaid rules,
b) the information provided by me in the Form, its supporting Annexures as well as in the documentary evidence are. to the best of my knowledge and belief,
true, correct and complete and that I have not withheld any material information that may aftect the assessment/categorization of the account as a Reporta
account or otherwise.
c) I permit/authorise the NPS Trust to collect, store, communicate and process information relating to the Account and all transactions therein, by the NPS Tru
and any of NPS intermediaries wherever situated including sharing, transfer and disclosure between them and to the authorities in and/or outside India of
any confidential information for compliance with any law or regulation whether domestic or foreign.
d) I undertake the responsibility to declare and disclose within 30 days from the date of change, any changes that may take place in the information 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,
e) I also agree that in case of my failure to disclose 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 (GOl) /RBI/IRDA/PFRDA 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
g) I also a~ree to furnish such information and/or documents as the NPS 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 / , - -- ~ eCL1b~J
Place : ,f~ .i~ A. ~ tji~j V ~ ~‘ 1~, —-— Signature/Thumb lmpression* of Subscriber in black ink
(* LTI in case of male and RTI in case of female)

Name of subscriber ]L~ ~i_~1 ~_Q _i~L ~T_J_L~_

KCRAO42-1 .1 FINTECH
Ver I I Annexure 52
5~fi~ B — Request for Reissue of PRAN card.
Re~ssue of PRAN card wW he chargeable to Subscriber/employer by CRA.

the aophcant, do hereby declare that the information provide ~bove is true to tite best oi my knowiedg

Signature/Thumb
Date lrnpreesion~ oF the Subscriber

Section 0 -~ Employment Details

1. GOVERNMENT SECTOR (Subscribers Emp~oyrnent Details to be filled and attested by the Dept.)
Date of Joining / / Date of Retirement / /
Empioyee Codo’lD (if apphcablo) . Erno oyes coos/ID and PRAN are optional. If you intend
PPAN (If applicable) . . . to provide, mention any one.
Group of Employee (Tick as apphcable) Group A Group B Group C Group D
Oh/ce .

Department . . . .

Ministry
Basic Pay
Pay Scale
It is certified that the employment details proaded above by ... employed with ~w, are as per the service
record of the employee maintained by us. Also, it is further certified that he/she has read entries/entries have been read over to him/her by us and got
confirmed by him/her.

Rgnature or the Authonsed person Rubber Stamp or the DOD Ggnature of the Authonsed person Rubber Stamp of the DTO/PAOI
(I t~ ox ~boxc) tin the box ab v~.) (In the box above) 0000,DTNPrAO (In the box above)
Detegnation of the Authonsed Person Designation ol the Authorised Person
DDO Registration Number DTO/PAO!C000/DTA1PrAO Registration Number . . .

Name of the DDO Narrie of DTO/PAO/CDDO/DTA/PrAO

Dept/Ministry Date / /

2. CORPORATE SECTOR (Subscribers Employment Details to be tilled and attested by Corporate.)

Date of Joining I / Date of Retirement / /
Employee Code/ID . . .

Corporate Regd. Number (CHO No.) Allotted by CRA

CBO No. allotted by CRA
It is certified that the employment details provided above by . employed with us, are as par the service

record of the employee maintained by us. Also, it is further certified that he/she has read entries/entries have been read over to him/her by us and got
.1 confirmed by him/her.
Date Place

Signature of the Authorisod person (In the box shove)

Designation of the Authonsed Person Rubber Stamp of the Corporate (In the i/ox above)
.~ To be filled by POP! POP-SP
~ KYC Compliance Yes
/ KYC document accepted for identrfy proof
/ KYC document accepted for address proof .

~ Copy of PAN card subntitted : Yes No

PAN Compliance : Yes

~ Signature of Authorized Signatory —__________

Namo: Place
POP? POP-SP Seal Designation Date : . /

KCRAD42- 1.1 4oi7 F NTFC .1

 ADD~ONAL NOM~NAT~ON FORM

INSTRUCTIONS FOR FILLING IN THE FORM

The details of nominees to whom the outstanding pension wealth of the subscriber is payable in case of the demise of the subscriber before er-tire
proceeds are withdrawn is to be provrded hereunder (Please refer instruction no: 5). Also, please note that in case of demise of the subscriber after opting
for deferred withdrawal, at the outstanding pension wealth present in the NPS account of the subscriber shall be wrthdrawn upon receiving the request
and paid to the nominees as mentioned in this form and the same would he treated as full and final discharge of the obligation.

hereby nominate the person(s) mentioned below who is/are member(s)!

of my family to receive the amount in my PRAN account under National Pensron System in the event of my death,

1. Name of the Nominee:

1st Nominee 2nd Nominee 3rd Nominee
First Name First Name •Firsi Name

Mrddle Name - Middle Name Middle Name

Lest Name Last Name Last Name

2. Present Communication address of the nominees:

Address of 1st Nominee Address of 2nd Nominee Address of 3rd Nominee

.~___~__..z~L._
3. Date of FSirth* (Only in case of a minor):

~ let Nominee / I 2nd Nominee / / 3rd Nominee - /

4, Relationship with the Nominee:

1st Nominee 2nd Nominee 3rd Nominee

L . ---

5. Percentage Share:

~ 1 at Nominee 2nd Nominee -- 3rd Nominee

6. Nominee’s Guardian Details (Only in case of a minor):

1st Nominees Guardian Details 2nd Nominee’s Guardian Details 3rd Nominee’s Guardian Details
First Name First Name . First Name .

Middle Name Middle Name Middle Name

Last Name - Last Name Last Name

l)ated this day el 2t) at

Signature’ Thumb lmpression~ of the Subscriber

~Note: Left thumb impression in case of illiterate male Subscriber and Right thumb impression in case of illiterate female subscriber must be obteined.

KCRAO42~l.1 Soti ~T.F~NTECH

 TO BE FILLED/ATTESTED BY POP-SP/DDO/NL.~CC

Cerffied that the above dectaration and nom~natLon details has been sgned / thumb impressed before roe by Sh/Srnt/Ms. .
after he / she have read the entries / entries have been read over to him / her by me and got confirmed by him / her.

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

POP.SP/DDO/NL-•CC Registration Number Designation of the Authorised Person

(Allotted by CRA)
POP-SP/DDO/NL.-CC Of/ice Name

Date / /

TO BE FILLEDIATTESTED BY POP!POP~SP/PAO/DTO/DTA/PrAOfNL4tO/NL~OO
POP/POP~SP/PAO/DTO/DTA]PrAO/NL.-AO’NL-OO Regmtration Number
(Allotted by CRA~

Rubber Stamp of the POP/POP-SP/PAO/DTO/DTA/PrAO/NL-AO/NLOO

Signature of the Authorised Person

KCRAO42-1.1 6of7 ~r~NTCCH

 V~r 1 1 Annexure S2
~NSTRUCTIONS FOR flLLING THE FORM
General Guidelines
(a) THe form a to b used for the ourposo of changoicorrcetbn in subscriber master details, reissue of PRAN card or employment details
(b) The form is to be suomitted at the Nodal 0 ‘ice for carrying out the necessary changes
(c) Please fick the box on the left margin of appropnaie row where change/correction is required and nrovirJe the details in the corresponding row. Please st~ke o Cthe iemaming
blank rows tar which no change is renuested.
td) Form lo be i lied legibly in BLOCK LETTERS ar’cI in BLACK iNK only.
(ai Details Marked with ti are tha mandatory fields. Menhon 12 dry ta FRAN corractiv.
(C) All Dates Should be m ‘DDMMYYYY” Format

S. Item
• Item Details Instructions
No No,
11 1 Spouse Name if married, spouse name is mandatory,
S,No Proof of Identity (Copy of any one) S.No Proof of Address (Copy of any one)
I Passport issued by Government of India. I Passport issued by Government of India
2 Ration caro with photograph. 2 Ration card with photograph and residential address
3 Bank Pass book or certificate mitit Photograph. 3 Bank Pass book or certificate with photograph and reaiderrtial.
address
4 Certificate cml Ihe POP hank for an axisf~ng Bank customer. 4 Certificate of the POP hank for an existing Bank customer.
S Voters identity card with photograph and residential 5 Voters Identity card with photograph and residential address
address.
6 Valid Driving I~cense with photograph 6 Valid Dnving license with photograph and residential address
7 Certificate of idemttity with pitotograph sigmted by a Merriher 7 Letter frorrt any recognized pubhc authority at the level
of Parliament or Member of Legislative Assernhly of Gazetted officer like District Magistrate, Divisional
commissioner. BOO, Tehsildar, Mandal Revenue Oflicer.
Judicial Magistrate etc.
8 PAN Card issued by Income tax department B Certificate of address with photograph signed by a Member
of Parliament or Member of Legislative Assembly
Identity,
Correspondence & 9 Aadhar Card / letter issLmed by Unique Identification fi Aadhar Card / letter issued by Unique Identification Authority
Permanent address Authonty of India of India clearly showing the address
details 10 Job cards issued by NREGA duly signed by an officer of 10 Job cards issued by NREGA duly signed by an officer of the
the State Government Stats Government
2 2.3&4 11 identity card issued by Certtrsl/State govermtmttemtt amtd Ii The identity card/document with address, issued by arty ol the
its Departments, statuary/ Regulatory Authorities, following: Central/State Government and its Departments.
Public Sector Undertakings, Scheduled commercial Statuary/Regulatory Authorities, Public Sector Undertakmngs,
Banks, Publ;c Financial Institutions, Colleges affiliated Scheduled Commercial Banks, PubIc Financial lnstiCitiorrs
to universities and Professional Bodies such as ICAI, for their employees
ICWAI, ICSI, LBar Council etc.
12 Photo Identity Card issi.ied by t,3efence Paramilitary and 12 Latest Electricity/water bill in the name of the Subscriber /
Police department’s Claimant and showing the address (less than 3 months old)
13 Ex-Service Mart Card issued by Ministry of Defence to 13 Latest Telephone bill in the name of the Subscriber / ClaimanL
their employees. and showing the address (less than 3 months old)
14 Photo Credit card. 14 Latest Property/house Tax receipt (rtot more than one year
old)
15 Existing valid registered lease agreement of the house on
stamp paper (in case of rented/leased accommodation)
Note:
(i) If the address on the document submitted for identity proof is same as that declared by subscriber in the form, the docum.ent tna~e
be accepted as a valid proof of both identity and address.
(ii) if the address irtdicated on the documnertt submitted for identity proof differs from tire current address mentioned in the
form, a separate proof of address should be obtaitted. All future corrirtturticatiorts will be sent to correspondence address, If
correspondence & Permanent address are different, then proof for both have to be submitted.
Politically Exposed Persons’ (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign
Poflulcally Exposed
country, for exantple heads of state or 01 the government, senior poliicians. senior government, juchcial or tailitary officials, senior
Person
executives of state-owned corporatiorts, imporiant political party officials.
in case, subscriber provides bank daHlia, it should be supported by cancelled ctteque.
Please attach a Cancelled cheque (containing Subscriber Name, Bank Account Number end IFS Code) or Battk Certificate
4 .~ Subscriber’s Bank uorttaining Name, Bank Account Number and IFS code, for direct credit or electronic transfer, In case if the cJteque is not preprinted
Details
with rmarne, additionally, a copy of the barmk passbook or hank certificate containing Name, Bank Accourtt Number and IFS code
should he submitted,
In case of more than one nominee, percentage share value for all the nominees must he integer. Decimals/Fractional values shall
~ Subscriber’s not he acceptod in the nomination(s). Sum of percentage share across all the nominees must he equal to 100, if sum of percentage
Nomination Details
is rmoi equal to 100, entire nomination will be rejected.
Clarification / Guidelittes on filling details ii applicant residemtce for tax purposes in j,urisdwion(s) outside irtdia
Jurisdiction(s) of Tax Residence: Since US taxes the global income of its citizen, every US citizett of whatever nationality, a also
a resident for tax purpose in USA.
T ax identification Number (TIN): TIN need rtot be reported if it has rtot been issued by the jurisdiction. However, if the said
Declaration by jurisdiction has issued a high integrity number with an equivalent level of identification (a “Functional equivalent”) the same
6 10 si,ih.scriber on may be reporied. Examples of that type of number for sadividual include, a social secLirity/insurance number, citizen/personal
FATCA Compliance identification/services code/nurrtber attd resident registration nurrtber)
if applicant residence for tax purpose in jurisdictiort(s) within India, Permanent Account Number (PAN) to he provided as Tax
Identification Number (TIN)
• In case applicant is declaring US person status as ‘No’ but his/her Country ‘of Birth is US. .docunaent evidencing Relinquishmei’it ii
of Citizemtship sttould be provided or ressotts for rtot itaving relin.quisftntertt certificate is to be provided
General Information for Subscribers
a) The Subscriber crari obtain the status of his/her application front their designated Nodal 0 ricer/employer,
b) Subscribers are advised to retain the ackriowledgemetnt sip sigmtedr stamped by the Nodal Ofc’cer / POPI POP-SF where titey subrri,t the appIicst~o i.
c) For more information, contact CRA:
Vlebsite:, https://nps.kfintech.com
Cell: 1800 208 1516
(siLfffBJfS KFin Technologies Private Limited
Selenium Tower-B, Plot No.31 & 32, Bachibowli,
Financial District, Nanrakramguda,Serilingawpally,
Hyderabad — 500032,Telangana, India

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