[Link].

in Attestation Form Antecedent Verification Form

ATTESTATION FORM
Latest colour
(THE CANDIDATES SHOULD PROPERLY FILL THE ATTESTATION passport size
FORM WITH HIS/HER OWN HAND WRITING) Photograph of
the candidate

Name of the Name of the Head

Department of the Dept.

1.(a) Name in full (capital letters only with aliases, if any. Please indicate if you
have added / dropped at any stage any part of your name/surname.

SURNAME

NAME

(b) Designation of the candidate with category (Appointment by Direct

Recruitment/Ex- Servicemen quote/compassionate ground)
Enclose supporting certified copies of the documents

(i) Designation

(ii) Place of Working

(iii) Direct recruitment Ex-Serviceman Compassionate

2. Details of addresses:
b. Permanent
a. Present

House/Apartment/Flat No.

Name of Apartment

Lane Name

Street & Road

Village

Mandal / Taluk

Town / City

District

State

Pin Code

APTF (257) PALNADU

 [Link] Attestation Form Antecedent Verification Form

Landline office Landline Residence

Mobile
(with STD Code) (with STD Code)
Contact Phone Numbers

(c) If originally a resident

Of Pakistan, the address
in that Dominion and the
date of migration to Indian
Union

3. Particulars of places where you have resided during the preceding five years
from the date of filling up if Attestation From.

Residential Address in full

( i.e., House / Apartment /
Flat Number)
From To Police station and
( Apartment/Complex/Lane/
(Month / Year) (Month / Year) District
Street/Colony and Road,
Village,Mandal and District/City)

1
2
3
4
5

4. Father’s details:
(a) Name in full with aliases, if any

(b) Profession

(c) If in service, give designation and

official address

(d) Present postal address (if dead, House No.

give last address
Lane Name
Street & Road
Village/Mandal
Dist
State
Pin Code

(e) Permanent House Address House No.

Lane Name
Street & Road
Village/Mandal
Dist
State
Pin Code

APTF (257) PALNADU

 [Link] Attestation Form Antecedent Verification Form

5. (i) Nationality of :
(a) Father

(b) Mother

(c) Wife / Husband

(ii) Place of Birth of Wife / Husband

6. (a) Date of birth of the applicant

(b) Present Age

(c) Age at SSC / Matriculation

7. (a) Place of birth, District and State

(b) District and State to which you belong

8. (a) Religion

(b)Are you member of Scheduled Caste / Scheduled Tribe / Backward Class?

Scheduled Caste Scheduled Tribe Backward Class

Please specify the Class / Tribe Grade A,B,C,D & E

9. Educational Qualifications showing places of education with years in schools and colleges since 15th
year of age (Please enclose certified copies of Study Certificates and indicate whether study is
regular or distance / correspondence).

Name of the
School / College Date of Date of Examination passed
with full entering leaving with [Link]. Police
Course address (mention (mention (Name of the group Station and
(Village / month month i.e.,Inter/Degree/ District
Mandal & year) & year) Diploma/ PG,etd
/ District / City
1. SSC/
Matriculation

[Link]/
Diploma
3. Graduation/
Professional
Course
4. Post
Graduation

5. Any other
qualification

APTF (257) PALNADU

 [Link] Attestation Form Antecedent Verification Form

10. If you have at any time been employed, give details, (Please enclose certified copies of the
documents).
Have you been at any
Designation of Post Period Full Address of the time dismissed /
held or description of Office, Firm or removed from service /
work From To Institution resigned to the post? If
so, please give details.

11. Have you ever been arrested by the police, convicted by a Court of law or detained under any
state /central preventive detention laws for any offence? Whether such conviction sustained in
the Court of Appeal or set aside by the Appellate Court if appealed against.
(Note: If detailed, convicted, debarred etc. subsequent to the completion and submission of this
form, the details should be communicated immediately to the concerned Department or the
authority to whom the Attestation Form has been sent earlier, as the case may be, failing which it
will be deemed to be suppression of factual information). If the answer is ‘Yes’, the full
particulars of the conviction, sentences and detention should be given.

12. Name and complete address of two responsible persons of your locality to whom you are known or
two referees to whom you are known. (Persons shall not be blood relatives).

Referee-1 Referee-2
Name

[Link]./Plot No.

Name of Apts./
Complex

Street & Road

Village

Mandal/Taluk

Town/City

District

State

Pin Code

13. Have you ever been member/worker of any Political Party or Communal
organization/Youth/Student/Service/Labour? If so furnish details

APTF (257) PALNADU

 [Link] Attestation Form Antecedent Verification Form

DECLARATION SHOULD BE SIGNED BY THE CANDIDATE

1. I here declare that the statements made in this form are true to the best of my knowledge and
belief.

2. I am married/unmarried and have only one wife living (delete which is not applicable).

3. I am fully aware that furnishing of false information or suppression of any factual information
in the Attestation Form would be a disqualification and is likely to render me unfit for
employment under the Government.

4. I am also fully aware that if it comes to notice at any time during my service that false
information has been furnished or that there has been suppression of factual information in the
Attestation Form, my services would be liable to be terminated solely on this ground.

Date: Signature of Candidate

Place:

CERTIFICATE TO BE SIGNED BY A GAZETTED OFFICER OR MEMBER OF

LEGISLATURE OR OTHER AUTHORITY AS PRESCRIBED BY THE
APPOINTING AUTHORITY

Certified that I have known Sri / Smt / Kum._________________________________________

__________________ Son / Daughter / Wife of ________________________________________

For the last ____________years___________ months and to the best of my knowledge and belief,

the particulars furnished by him / her are correct.

Date: (Signature)
Name & Designation with Seal
Place:

Photograph of the
candidate attested
by Gazetted Officer
/ MLA / other with
seal Competent
Authority

APTF (257) PALNADU

(Ver-2) CSRF 1
NATIONAL PENSION SYSTEM (NPS)
SUBSCRIBER REGISTRATION FORM
Affix
Please Select your Category [ Please tick(√) ] recent colour
photograph
To, Government Sector Corporate Sector of
3.5 cm X 2.5 cm
National Pension System Trust. All Citizen Model NPS Lite/Swavalamban size
Dear Sir/Madam,
I hereby request that an NPS account be opened in my name as per the particulars given below:
* indicates mandatory fields. Please fill the form in English and BLOCK letters with black ink pen. (Refer general guidelines at instructions page)
1. PERSONAL DETAILS:
Name of Applicant in full Shri Smt. Kumari
First Name*
Middle Name
Last Name
Date of Birth* d d / m m / y y y y (Date of Birth should be supported by relevant documentary proof)

Gender* [ Please tick (√) ] Male Female Others

Father's Name* F i r s t M i d d l e L a s t
(Refer Sr. No. 1 of instructions)

2. IDENTITY DETAILS* (Any one of the documents need to be provided)

PAN Aadhaar Voter ID

Passport Others Name of the ID I D N u m b e r Please refer Sr. No. 2 of the instructions.

3. CORRESPONDENCE ADDRESS DETAILS*

Flat/Room/Door/Block no. Landmark
Premises/Building/Village
Road/Street/Lane
Area/Locality/Taluk
City/Town/District PIN Code
State/U.T. C o u n t r y

4. PERMANENT ADDRESS DETAILS Tick (√) in the box in case the address is same as above.

Flat/Room/Door/Block no. Landmark

Premises/Building/Village
Road/Street/Lane
Area/Locality/Taluk
City/Town/District PIN Code
State/U.T. C o u n t r y

Proof of Address (Correspondence/Permanent)

Aadhar card Passport Voter ID card Driving License Ration Card Registered Lease Sale agreement of residence
Latest Gas Bill #
Electricity Bill #
Telephone[Landline] Bill #
Others (please specify)
#
Not more than 3 months old. Please refer Sr. No. 2 of the instructions

5. CONTACT DETAILS
Landline Phone (with STD Code) Mobile + 9 1
Email ID
Do you want to subscribe to SMS Alerts : Yes No Mobile number is essential for receiving sms alerts regarding your NPS account

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

 Occupation Details [ please tick(√) ]
Private Sector Government Sector Public Sector Business Professional Agriculture
Homemaker Student NRI Other (please specify)

 Please Tick If Applicable Politically exposed person Related to Politically exposed Person
 Income Range (per annum) Upto 1 lac 1 lac to 5 lac 5 lac to 10 lac 10 lac to 25 lac 25 lac and above
 Educational Qualifications Below SSC SSC HSC Graduate Masters Professionals ( CA, CS, CMA, etc.)

7. SUBSCRIBER BANK DETAILS ( Please refer to Sr no. 4 of the instructions )

Account Type [ please tick(√) ] Saving A/c Current A/c
Bank A/c Number
Bank Name
Branch Name
Branch Address PIN Code
State/U.T. C o u n t r y
Bank MICR Code IFSC Code

APTF (257) PALNADU 1 of 3

(Ver-2) CSRF 1
8. SUBSCRIBERS NOMINATION DETAILS* (Please refer to Sr. No . 5 of the instructions)
Name of the Nominee (You can nominate up to a maximum of 3 nominees and if you desire so please fill in Annexure III (Additional Nomination Form) provided separately)
Nominee Name F i r s t M i d d l e L a s t
Relationship with the Nominee Date of Birth (In case of Minor) d d / m m / y y y y
Nominee’s Guardian Details (in case of a minor)
Nominee’s Guardian F i r s t M i d d l e L a s t

9. NPS OPTION DETAILS (Please tick (√) as applicable)

I would like to subscribe for Tier II Account also YES NO If yes, please submit details in Annexure I. (Tier II account is not available for NPS Lite/
Swavalamban subscribers).
I would like my PRAN to be printed in Hindi YES NO If Yes, please submit details on Annexure II

10. PENSION FUND (PF) SELECTION AND INVESTMENT OPTION*

(i) PENSION FUND SELECTION (Tier I) : The names of the all PFs are mentioned in the instructions page and are available to the all sector
subscribers with following conditions:
(i) Government Sector: For Government Subscribers, the following PFs act as default PFs as per the guidelines issued by the Government:
(a) LIC Pension Fund Limited (b) SBI Pension Funds Pvt. Limited (c) UTI Retirement Solutions Ltd.
(ii) NPS Lite/Swavalamban: NPS Lite Swavalamban is a group choice model where subscriber has a choice of PF and investment option as available with Aggregator.
(iii) All Citizen Model: Subscribers under All Citizen model has the option to choose the available PFs as per their choice in the table below.
(iv) Corporate Model: Subscribers shall have the option to choose the available PFs as per the below table in consultation with their respective Employer.

Name of the Pension Fund Please Tick (√) Availability of the Pension Funds
LIC Pension Fund Limited
Available to
SBI Pension Funds Private Limited Government
Sector
UTI Retirement Solutions Limited
Available to Available to
Available to All
ICICI Prudential Pension Funds Management Company Limited NPS Lite/ Corporate
Citizen Model*
Swavalamban Model*
Kotak Mahindra Pension Fund Limited
Reliance Capital Pension Fund Limited
HDFC Pension Management Company Limited
* Selection of Pension Fund is mandatory both in Active and Auto Choice. In case, you do not indicate a choice of PF, please note that it is deemed that you have consented
for the default PF specified by PFRDA. Currently, SBI Pension Funds Private Limited is the default PF.

(ii) INVESTMENT OPTION (Available for All Citizen Model and Corporate Model Subscribers)
( Please Tick (√) in the box given below showing your investment option).
Active Choice Auto Choice
For details on Auto Choice, please refer to the Offer Document. Please note:
1. In case you do not indicate any investment option, your funds will be invested in Auto Choice
2. In case you have opted for Auto Choice, DO NOT fill up section below relating to Asset Allocation. In case you do, the Asset Allocation instructions will be ignored
and investment will be made as per Auto Choice.
(iii) ASSET ALLOCATION (to be filled up only in case you have selected the ‘Active Choice’ investment option)
E
Asset Class C G Total Note:- The total allocation across E, C and G asset classes must be equal to
(Cannot exceed 50%)
100%. In case, the allocation is left blank and/or does not equal 100%, the
% application shall be rejected.

11. DECLARATION BY SUBSCRIBER* ( Please refer to Sr no. 6 of the instructions )

Declaration & Authorization by all subscribers
I have read and understood the terms and conditions of the National Pension System and hereby agree to the same and declare that the information and documents furnished
by me are true and correct, to the best of my knowledge and belief. I undertake to inform immediately the Central Record Keeping Agency/National 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 liable 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 PFRDA, whether
complete or partial 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/NPSCAN and view
details) & T-pin on the CRA website.
Additional declaration by Swavalamban subscriber
I have read/explained to me and understood the Swavalamban guidelines and I meet the prescribed eligibility criteria for assistance under the scheme. I also undertake to
adhere to the prescribed contribution limit of minimum Rs. 1000/- and maximum of Rs. 12000/-, failing which the Central Government contribution credited to my account
may be forfeited along with such interest rates as may be prescribed.
Declaration under the Prevention of Money Laundering Act, 2002
I hereby declare that the contribution paid by me/on my behalf has been derived from 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 right to close my PRAN in case I am
found violating the provisions of any law relating to prevention of money laundering.

Date d d / m m / y y y y

Place :

Signature/Thumb Impression* of Subscriber in black ink

(* LTI in case of male and RTI in case of female)

ACKNOWLEDGEMENT
Name of the Subscriber:
Contribution Amount Remitted: `

Date of Receipt of Application and Contribution Amount: d d / m m / y y y y

Stamp and Signature of the Employer/PoP/Aggregator:

APTF (257) PALNADU 2 of 3

(Ver-2) CSRF 1
12. DECLARATION BY EMPLOYER/POP/AGGREGATOR
Applicable to Government Subscribers only
(Subscribers Employment Details to be filled and attested by the Deptt. (All Details are Mandatory)
Date of Joining d d / m m / y y y y Date of Retirement d d / m m / y y y y
Employee Code/ID
Group of Employee (Tick as applicable) Group A Group B Group C Group D
Office

Department

Ministry

DDO Registration Number

DTO/PAO/CDDO/DTA/PrAO Registration Number Basic Pay

Pay Scale

It is certified that the details provided in this subscriber registration form by ______________________________________________________ employed with us,
including the address and employment details provided above 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.

Signature of the Authorised person Rubber Stamp of the DDO Signature of the Authorised person Rubber Stamp of the DTO/PAO/CDDO/
(In the box above) (In the box above) (In the box above) DTA/PrAO (In the box above)
Designation of the Authorised Person Designation of the Authorised Person
Name of the DDO Name of DTO/PAO/CDDO/DTA/PrAO
Deptt/Ministry Date d d / m m / y y y y

Applicable to Corporate Subscribers only

(Subscribers Employment Details to be filled and attested by Corporate (All Details are Mandatory))
Date of Joining d d / m m / y y y y Date of Retirement d d / m m / y y y y

Employee ID

Corporate Regd. No Allotted by CRA CBO No. allotted by CRA

Certified that the details provided in this subscriber registration form by ________________________________________________________ employed with us, including
the employment details provided above are as per the service record of the employee maintained by us. Also, it is further certified that he / she has read the entries / entries
have been read over to him / her by us and got confirmed by him / her.

Date d d / m m / y y y y

Signature of the Authorized Person (In the box above) Place Rubber Stamp of the Corporate
Designation of the Authorized Person: (In the box above)

To be filled by POP-SP (Only in case of All Citizen Model or Corporate subscribers)

Receipt No. (17 digits) POP-SP Registration Number

Document accepted for date of Birth Proof:

Copy of PAN card submitted YES NO KYC Compliance YES NO
Existing Bank Customer:
I/we hereby certify/confirm that Shri/Smt/Kum …..…………..........................................…………….......... is an existing customer of the Bank having fully operative Saving
Bank account no ...………......…....................................at ………......………..... branch and KYC norms required for opening Bank Account which match the requirements
for opening NPS account have been fully complied with. We further confirm that the S. B. a/c of Sh/Smt/Kum ……........….............................................................…..........
is not a ‘Basic Savings Bank Deposit Account’.
Adhaar Based KYC Certificate:
I/we hereby certify that Aadhaar Number ...………......…....................................of Sh/Smt/Kum………………….......................................................................…..has been
checked and the name and address mentioned on the original Aadhaar card are matching with that mentioned on NPS application form.

To be filled by POP-SP Name:

Designation: Place:

POP-SP Seal Signature of Authorized Signatory Date d d / m m / y y y y

Declaration by the Aggregator (Only in case of NPS Lite/Swavalamban Subscribers)

Authorisation by Aggregator’s office (NL - AO)
Certified that the subscriber is registered with the aggregator and he/she has opted to join NPS. I hereby declare that the subscriber is eligible to join NPS and the above
declaration has been signed /thumb impressed before me by ...................................................after (s)he has read the entries/ entries have been read over to her/him by me.

Signature of the Authorised person (In the box above) Rubber Stamp of the Aggregator (In the box above)
Name of the Aggregator

NPS Lite Account Office (NL-AO) Registration Number NPS Lite - Collection Centre (NL - CC) Registration Number
Membership No. allotted by Aggregator (if any)
Place Date d d / m m / y y y y

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

Received by CRA-FC Registration Number
Received at Date d d / m m / y y y y
Acknowledgement Number (by CRA-FC)
PRAN Alloted

APTF (257) PALNADU 3 of 3

(Ver-2) CSRF 1
INSTRUCTIONS FOR FILLING THE SUBSCRIBER REGISTRATION FORM
General Guidelines
(a) Please fill the form in legible handwriting so as to avoid errors in your application processing. Please do not overwrite. Corrections should be made by cancelling and re-writing
and such corrections should be countersigned by the applicant. Each box, wherever provided, should contain only one character (alphabet / number / punctuation mark) leaving
a blank box after each word.
(b) Applications incomplete in any respect and/or not accompanied by required documents are liable to be rejected. The application is liable to be rejected if mandatory fields are
left blank or the application form is printed back to back
(c) The subscriber should not sign across the photograph. The photograph should not be stapled or clipped to the form. If there is any mark on the photograph such that it hinders
the clear visibility of the face of the subscriber, the application shall not be accepted.
(d) Copies of all the documents submitted by the applicant should be self-attested and accompanied by originals for verification by the nodal office.
(e) Name and Address of the applicant mentioned on the form, should match with the documentary proof submitted.
(f) The subscriber’s thumb impression should be verified by the DDO/PAO/DTO/designated officer of POP-SP/Aggregator
(g) Government employees (mandatorily covered under NPS) may submit their application for Tier II to any POP-SP of their choice. The list of POP-SPs rendering services under
NPS is available on CRA website [Link]

[Link] Item No. Item Details Instructions

Date of Birth Please ensure that the date of birth matches as indicated in the document provided in the support.
i. If father's name has more than 30 digits, you may fill Annexure II for the same.
1 1 ii. Father’s name is mandatory. However, if applicant does not want to provide father’s name, he/she has an option to provide
Father's Name
mother’s name on Annexure II and the mother’s name will be printed on PRAN card
iii. If the applicant wants mother’s name to be printed instead of Father’s name on PRAN Card, he/she must fill Annexure II
[Link] Proof of Identity (Copy of any one) [Link] Proof of Address (Copy of any one)
1 Passport issued by Government of India. 1 Passport issued by Government of India
2 Ration card with photograph. 2 Ration card with photograph and residential address
Bank Pass book or certificate with photograph and
3 Bank Pass book or certificate with Photograph. 3
residential address
4 Certificate of the POP bank for an existing Bank customer. 4 Certificate of the POP bank for an existing Bank customer.
Voters Identity card with photograph and residential Voters Identity card with photograph and residential
5 5
address. address
Valid Driving license with photograph and residential
6 Valid Driving license with photograph 6
address
Letter from any recognized public authority at the level
Certificate of identity with photograph signed by a Member of Gazetted officer like District Magistrate, Divisional
7 7
of Parliament or Member of Legislative Assembly commissioner, BDO, Tehsildar, Mandal Revenue Officer,
Judicial Magistrate etc.
Certificate of address with photograph signed by a Member
Identity, 8 PAN Card issued by Income tax department 8
of Parliament or Member of Legislative Assembly
Correspondence &
2 2, 3 & 4 Aadhar Card / letter issued by Unique Identification Aadhar Card / letter issued by Unique Identification
Permanent address 9 9
Authority of India Authority of India clearly showing the address
details
Job cards issued by NREGA duly signed by an officer of Job cards issued by NREGA duly signed by an officer of
10 10
the State Government the State Government
Identity card issued by Central/State government and its The identity card/document with address, issued by
Departments, statuary/ Regulatory Authorities, Public any of the following: Central/State Government and its
Sector Undertakings, Scheduled commercial Banks, Public Departments, Statuary/Regulatory Authorities, Public
11 11
Financial Institutions, Colleges affiliated to universities Sector Undertakings, Scheduled Commercial Banks,
and Professional Bodies such as ICAI, ICWAI, ICSI, Bar Public Financial Institutions for their employees.
Council etc.
Photo Identity Card issued by Defence, Paramilitary and Latest Electricity/water bill in the name of the Subscriber
12 12
Police departments. showing the address (less than 3 months old)
Ex-Service Man Card issued by Ministry of Defence to their Latest Telephone bill in the name of the Subscriber showing
13 13
employees. the address (less than 3 months old)
Latest Property/house Tax receipt (not more than one
14
year old)
14 Photo Credit card.
Existing valid registered lease agreement of the house on
15
stamp paper ( in case of rented/leased accommodation)
Note:
(i) If the address on the document submitted for identity proof by the prospective customer is same as that declared by him/her in
the account opening form, the document may be accepted as a valid proof of both identity and address.
(ii) If the address indicated on the document submitted for identity proof differs from the current address mentioned in the account
opening form, a separate proof of address should be obtained. All future communications will be sent to correspondence
address. If correspondence & Permanent address are different, then proof for both have to be submitted.
(iii) In case of Government subscribers, the KYC documents may be submitted within a period of 30 days after generation of PRAN.
Other Details An NRI subscriber would need to furnish an Indian address for communication and bank details within India. Fund transfers by NRIs
(Occupation Details) would be subject to regulatory requirements as prescribed by RBI from time to time and FEMA requirements.
3 6 Politically Exposed Persons’ (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign
Politically Exposed
country, for example heads of state or of the government, senior politicians, senior government, judicial or military officials, senior
Person
executives of state-owned corporations, important political party officials.
For Tier I, bank details are optional. For activation of Tier II, bank details are mandatory. Please attach a Cancelled cheque (containing
Subscriber’s Bank Subscriber Name, Bank Account Number and IFS Code) or Bank Certificate containing Name, Bank Account Number and IFS code,
4 7
Details for direct credit or electronic transfer. In case if the cheque is not preprinted with name, additionally, a copy of the bank passbook or
bank certificate containing Name, Bank Account Number and IFS code should be submitted.
In case of more than one nominee, percentage share value for all the nominees must be integer. Decimals/Fractional values shall
Subscriber’s Nomination
5 8 not be accepted in the nomination(s). Sum of percentage share across all the nominees must be equal to 100. If sum of percentage
Details
is not equal to 100, entire nomination will be rejected.
Signature / Thumb impression should only be within the box provided in the form. Thumb impression, if used, should be attested
Declaration by
6 12 by the nodal officer with the official seal and stamp. Left Thumb Impression in case of male and Right Thumb Impression in case of
Subscriber
female.

General Information for Subscribers

a) The Subscriber can obtain the status of his/her application from CRA and their designated nodal officer.
b) Subscribers are advised to retain the acknowledgement slip signed/ stamped by the designated nodal officer where they submit the application.
c) For more information / clarifications, contact CRA:
Website: [Link]
Call: 022-2499-4200
e-mail: [Link]@[Link]
Address: Central Recordkeeping Agency, NSDL e-Governance Infrastructure Limited, 1st Floor, Times Tower, Kamala Mills Compound, Senapati Bapat Marg,
Lower Parel (W), Mumbai - 400 013.

APTF (257) PALNADU

 Proforma/ Application for New CFMS/HRMS Id
1 First Name (As per the SR of the Employee) :

2 Surname (As per the SR of the Employee) :

3 Father's Name :

4 Date of Birth :

5 Gender :

6 Date of Joining into Government Service :

7 Marital Status :

8 If married, Spouse Name :

9 Employees Office Name :

10 Designation :

11 House No, Address :

12 Land Mark :

13 Street Name :

14 Pincode :

15 Email :

16 Cell No :

17 Bank IFSC Code :

18 Bank Account Number :

19 Aadhra Number :

20 PAN Number :

Attachments:
1 Appointment Proceeding Scanned Copy
2 Attach Copy of Bank Passbook Signature of the Employee
3 Attach copy of Aadhar Card
4 Attach copy of PAN Card
5 SSC Certificate

[Link]

APTF (257) PALNADU

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APTF (257) PALNADU

 Annexure S6

Covering Letter with Subscriber Registration Application Form

(To be submitted by PAO in duplicate on official stationery)

To NSDL CRA,
From: Date:
PAO Registration Number:
PAO Department/Ministry:
PAO Contact No.:
Enclosed please find DDO wise Subscriber Registration Forms along with the covering
letter from the respective DDOs for the purpose of allotment of Permanent Retirement
Account Number (PRAN). The Details of the DDO are as listed below:
Sr. DDO DDO Office Number Total Number of Forms (in words)
No. Registration of
Number Packets

Total number of forms attached

I the authorized signatory, do hereby declare that what is stated above is correct and
complete.
Yours faithfully,

__________________________ _____________________________
Signature/Name of Authorised Signatory Acceptance Date and Stamp of FC branch:
Stamp of PAO
------------------------------------------------------------------------------------------------------------
Instructions:
1. This covering letter is to be provided by the PAO along with the subscriber registration
forms.
2. The total number of forms per DDO covering letter in a single packet should not exceed 50.
3. The subscriber application forms should be arranged DDO wise along with the respective
DDO covering letter in the same order as mentioned above.
4. The Provisional Receipt Number will be issued DDO wise.
5. Please quote the correct PAO Reg. No. allotted by CRA.. The forms are liable to be
rejected if incorrect PAO Reg. No. is mentioned.
--------------------------------------------------------------------------------------------------------------

APTF (257) PALNADU

 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.:

Enclosed please find ___________________________ (in words) number of

Subscriber 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 Acceptance Date and Stamp of FC branch
Stamp of DDO
------------------------------------------------------------------------------------------------------------
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 [Link]. allotted by CRA. The forms are liable to be
rejected if incorrect DDO Reg. No. is mentioned.
--------------------------------------------------------------------------------------------------------

APTF (257) PALNADU

 APPLICATION FOR POLICY
FyÌÁ{qs µR¶LRiÆØxqsVò

Form – 1
FnyLRiLi c 1

DIRECTORATE OF INSURANCE
\® ²¶lLiNíRPlLiÉÞ A£msn B©«sW=lLi©±s=
GOVERNMENT OF ANDHRA PRADESH
ALiúµ³R¶ úxms®µ¶[a`P úxms˳ÁÏ V»R½*ª«sVV
HYDERABAD
\|¤¦¦¦µR¶LSËص`¶
DISTRICT INSURANCE OFFICE ___________
ÑÁÍýØ ÕdÁª«sW NSLSùÌÁ¸R¶Vª«sVV ___________
PROPOSAL FORM
úxms¼½FyµR¶©«s xmsú»R½ª«sVV
All Columns shall be filled in capitals only
@¬sõ NSÌÁª«sVVÌÁV |msµô¶R @ORPQLRiª«sVVÌÁ»][ xmspLjiògS ¬sLixmsª«sÛÍÁ©«sV
Policy No. ___________ Proposal Form No. ___________
FyÌÁ{qs ®©sLi. ___________ úxms¼½FyµR¶©«s ®©sLi. ___________
1. Name }msLRiV
Surname BLiÉÓÁ }msLRiV Full Name xmspLjiò }msLRiV 2. Sex Male / xmsoLRiVxtsv²R¶V
Female / {qsòQû

3. Father’s Name »R½Liú²T¶ }msLRiV 4. Designation x¤¦Ü[µy

5. Employee Office Address Dµ][ùgji NSLSùÌÁ¸R¶V ÀÁLRiV©yª«sW 6. Date of Birth xmsoÉíÁÓ ©«s ¾»½[µj¶ D D M M Y Y Y Y
(As per Service Register)
xqsLki*£qs LjiÑÁxtísQL`i úxmsNSLRiLi

P I N

7. Date of First Appointment ®ªsVVµR¶ÉÓÁ ¬s¸R¶Wª«sVNRPxmso ¾»½[µj¶ D D M M Y Y Y Y

8. Marital Status sªyz¤¦¦¦»R½VÍØ / @ sªyz¤¦¦¦»R½VÍØ / s»R½Li»R½Vªy / s²yNRPVÌÁV

Married Unmarried Widow Divorced

9. If married, No. of Children and their ages zmsÌýÁÌÁ xqsLiÅÁù ª«s¸R¶VxqsV= (xqsLi. ÍÜ[)
sªyz¤¦¦¦»R½V\ÛÍÁ¾»½[ zmsÌýÁÌÁ qx sLiÅÁù ª«sVLji¸R¶VV ªyLji ª«s¸R¶VxqsV=

10. Basic Pay and Pay Scale ª«sVWÌÁ ®ªs[»R½©«sª«sVV ª«sVLji¸R¶VV ®ªs[»R½©«sª«sVV }qsäÌÁV

11. DETAILS OF NOMINATION ©y sV®©s[tx sQ©s« V sª«sLSÌÁV

S. No. Name of Nominee Name of Nominee’s Father Age Relationship of Nominee Share
úNRPª«sV xqsLiÅÁù ©y sV¬s }msLRiV ©y sV¬s ¹¸¶VVNRPä »R½Liú²T¶ }msLRiV ª«s¸R¶VxqsV= ¿RÁLiµyµyLRiV¬sNTP ©yª«sV¬s»][ xqsLiÊÁLiµ³R¶Li ªyÉØ

12. Are you in Good Health úxmsxqsVò»½R Li dsV AL][giR ùLi ËØgRiVgS ª«so©«sõµy ( ) Tick Yes / @ª«so©«sV No / NSµR¶V

(Contd – 2)

APTF (257) PALNADU

 :: 2 ::

13. Have you in the preceeding (3) years been absent on Leave on Yes / @ª«so©«sV No / NSµR¶V
Medical Grounds for more than (10) days at a
time ? If Yes, give details
gRi»R½ ª«sVW²R¶V qx sLiª«s»R½=LSÌÁÍÜ[ dsVLRiV \®ªsµR¶ù NSLRißØÌÁ \|ms IZNP[ryLji (10) L][ÇÁÙÌÁNRPV \|msgS
|qsÌÁª«so \|ms \lgiLRiV¥¦¦¦ÇÁLRi¸R¶WùLS ? @LiVV¾»½[ A sª«sLSÌÁV ¾»½ÌÁxmsLi²T¶
14. 1. Have you ever suffered from any of the following Diseases :-
C úNTPLiµj¶ }msL]ä©«sõ ªyùµ³R¶VÌÁÍÜ[ ®µ¶[¬s»][\®©s©y dsVLRiV FsxmsöV\®²¶©y Ëص³R¶mx s²ïyLS ?

Fs. Heart Ailment gRiVLi®²¶ªyùµ³¶j Yes / @ª«so©«sV No / NSµR¶V

ÕÁ. Kidney ª«sVWú»R½zmsLi²R¶Li Yes / @ª«so©«sV No / NSµR¶V

zqs. Cancer NSù©«s=LRiV Yes / @ª«so©«sV No / NSµR¶V

²T¶. Lungs EzmsLji ¼½»R½VòÌÁV Yes / @ª«so©«sV No / NSµR¶V

2. If Yes, give details of Disease, duration and Treatment received

xqsª«sWµ³y©«sª«sVV @ª«so©«sV @LiVV©«s, ªyùµ³j¶ sª«sLSÌÁV, ÀÁNTP»R½= ¼d½qx sVN]¬s©«s \®ªsµR¶ù }qsª«sÌÁ sª«sLSÌÁV
¾»½ÌÁöLi²T¶

15. Are you a physically challenged person. If so, enclose Certificate issued Yes / @ª«so©«sV No / NSµR¶V
by a Competent Authority
dsVNRPV G\®µ¶©y aSLkiLRiNRP ÍÜ[mx sLigS¬s \®ªsNRPùÌÁLigS¬s D©«sõQÈýÁLiVV¾»½[ @ÉíÁÓ @LigRi\®ªsNRPÌÁùLi sª«sLSÌÁV ¾»½ÌÁxmsLi²T¶,
\®ªsµyùµ³j¶NSLji ÇØLki ¿Á[zqs©«s @LigRi\®ªsNRPÌÁùLi µ³R¶Xª«sxmsú»y¬sõ qx sª«sVLjiöLi¿RÁLi²T¶

16. If already insured Policy No. Total Monthly Premium

Bµj¶ª«sLRiZNP[ ÕdÁª«sW ¿Á[zqsD©«sõ¿][ FyÌÁ{qs ®©sLi. ®©sÌÁxqsLji ú{ms sV¸R¶VL ®ªsVV»R½Lò i

17. Proposed Monthly Premium úxms¼½Fyµj¶LiÀÁ©«s ®©sÌÁxqsLji ú{ms sV¸R¶VLi

18. Month and Year of Recovery »R½gæij Lixmso ÇÁLjigji©«s ®©sÌÁ ª«sVLji¸R¶VV xqsLiª«s»R½=LRiLi

19. Mobile No. ®ªsVV\ÛËÁÍÞ ®©sLi.

20. Email Address B®ªsVVLiVVÍÞ ÀÁLRiV©yª«sW 21. Aadhar Card No. Aµ³yL`i NSL`iï ®©sLi.

22. Employee ID No. Dµ][ùgji gRiVLjiòLixmso ®©sLi.

23. Major Head |msµôR¶ xmsµôR¶V Try. D. D. O. Code úÛÉÁÇÁLki ²T¶. ²T¶. J. N][²`¶

úxms¼½FyµR¶NRPV¬s LRiW²³¶T úxmsNRPÈÁ©«s

Declaration by the Proponent

"úxmsaRPõÌÁ©«sV xmspLjigS @LóiR Li ¿Á[qx sVNRPV©«sõ »R½LS*»R½ ®©s[©«sV \|ms©«s ¾»½ÖÁzms©«s sª«sLRiª«sVVÌÁV Bª«s*²R¶ª«sVLiVVLiµj¶. @ s ©yxqs*µR¶qx sWòLij »][
úªyzqsLi\®µ¶©«s©«sV NSNRPF¡LiVV©«s©«sV úxms¼½ @LiaRPLi ¸R¶Vµ³yLóiR Li, xqsª«sVúgRiLi, xqsLixmspLñiR Li @LiVV©«sª«s¬s¸R¶VV G xmsLjizqós»R ½VÌÁNRPV xqsLiÊÁLiµ³j¶LiÀÁ ®©s[©«sV xqsª«sW¿yLRiª«sVV
@LiµR¶Â¿Á[¸¶R Vª«sÌÁzqs¸R¶VV©«sõµ][ A xmsLjizqós»R½VÌÁ©«sV ¬sÖÁzms®ªs[¸¶R VÛÍÁ[µR¶¬s¸R¶VV ÛÍÁ[µy LRix¤¦¦¦xqsùLigS ª«soLi¿RÁÛÍÁ[ µ¶R ¬s¸R¶VV ®©s[©«sV BLiµR¶V ª«sVWÌÁª«sVVgS úxmsNRPÉÓÁLi¿RÁV¿RÁV©yõ©«sV. \|ms
sª«sLRißáÌÁV ª«sVLji¸R¶VV C úxmsNRPÈÁ©«s ÕdÁª«sW N]LRiNRPV úxms¼½Fyµj¶LiÀÁ©«s IxmsöLiµy¬sNTP úFy¼½xmsµj¶NRPÌÁVgS ª«soLi²yÌÁ¬s¸R¶VV ®©s[©«sV ÊÁVµô¶ðj mx spLRi*NRPLigS, G\®µ¶©y xqs»R½ù µR¶WLRi\®ªsV©«s
sª«sLRißá©«sV ¿Á[zqs©«sÈýÁVgS¬s, ¾»½ÖÁ¸R¶VxmsLRi¿RÁª«sÌÁzqsª«so©«sõ G\®µ¶©y xmsLjizqós¼½¬s ®ªsWxqsxmso ÊÁVµô¶ðj »][ µyÀÁ ª«soLiÀÁ©«sÈýÁVgS¬s, BLiµR¶V dsVµR¶ÈÁ NRP©«sVg]©«sõ ¹¸¶V²R¶ÌÁ xqsµR¶LRiV
NSLiúÉØNíRPV úNTPLiµR¶ ¿ÁÖýÁLiÀÁ¸R¶VV©«sõ ú{ms sV¸R¶Vª«sVVÌÁ¬sõLiÉÓÁ¬s N][ÍÜ[öª«sÛÍÁ©«s¬s¸R¶VV, A IxmsöLiµR¶Li xqsLix mspLñiR LigS LRiµôR¶V NSª«sÌÁ©«s¬s¸R¶VV ®©s[©«sV IxmsöVN]©«sV¿RÁV©yõ©«sV."
(Contd – 3)

APTF (257) PALNADU

 :: 3 ::

“I do hereby declare that the foregoing details and Answers have been given by me after fully
understanding the questions, the same are true, full and complete whether written in my own hand writing or not in
every particular and that I have not withheld or concealed any circumstances with regard to which information has
been required from me. I agree that the foregoing statements and declaration shall be the basis of the proposed
contract for an Insurance and that if it shall hereafter appear that I have willfully made any untrue statement or
have fraudulently concealed any circumstances which I ought to have made known then all the Premia which shall
have been paid under the said contract shall be forfeited and the contract rendered absolutely null and void.”

¾»½[µj¶ ÒÁ s»R½ ÕdÁª«sW ¿Á[¸¶R VµR¶ÌÁÀÁ©«s ª«sùQQNTPò xqsLi»R½NRPLi

Date Signature

úxms¼½FyµR¶©«s \|ms G @µ³j¶NSLji xqsª«sVORPQLiÍÜ[ xqsLi»R½NRPLi ¿Á[¸R¶VÊÁ²T¶©«sµ][ A @µ³j¶NSLji µ³¶R X sd NRPLRißá xmsú»R½Li
CERTIFIED BY OFFICER BEFORE WHOM THE PROPOSAL IS SIGNED

|\ ms©«s }msL]ä©«sõ xqsLki*xqsV sª«sLSÌÁV xqsLji\¹¸¶V©«sª«s¬s¸R¶VV, úxms¼½FyµR¶NRPV²R¶V ©y xqsª«sVORPQLiÍÜ[ xqsLi»R½NRPLi ¿Á[zqs©y²R¶¬s¸R¶VV ®©s[©«sV
µ³R¶Xª«sxmsLRiVxqsVò©«s©y©«sV. ©«sW»R½©«s / @µR¶©«sxmso ÕdÁª«sW ¬s sV»R½ªò «sVV »R½gæij Lixmso ¿Á[zqs©«s ®ªsVVµR¶ÉÓÁ ú{ms sV¸R¶VLi LRiW. ________________ ª«sVLji¸R¶VV ®ªsVV»R½ªò «sVV
LRiW. ___________ (Bµj¶ ª«sLRiZNP[ »R½gæij Lixmso ¿Á[zqs©«s ª«sVLji¸R¶VV úxmsxqsVò»½R ú{ms sV¸R¶VLi NRPÌÁVxmsoN]¬s) ___________ ®©sÌÁ ª«sVLji¸R¶VV ___________
xqsLiª«s»R½=LRiª«sVV ®ªs[»½R ©«sª«sVV ©«sVLi²T¶ ¾»½[µj¶ ___________ gRiÌÁ ÉÜ[NRP©±s ®©sLiÊÁLRiV ___________ µy*LS ª«sxqsWÌÁV ¿Á[¸¶R V²R¶ª«sVLiVV©«sµj¶.

I certify that the service particulars stated above are correct and the Proponent’s Signature has
been affixed in my presence. The First Premium recovered for fresh /subsequent Insurance is ___________ in
all _____________ (including previous and present Premium) from the pay of _________________ month and
_____________ year, vide token No. ____________ dated __________________

xqósÌÁLi xqsLi»R½NRPª«sVV
Station Ax¤¦¦¦LRißá ª«sVLji¸R¶VV ÊÁÉØ*²R¶ @µ³j¶NSLji (Ax¤¦¦¦LRißá ª«sVLji¸R¶VV
ÊÁÉØ*²R¶ @µ³j¶NSLji gRiÑÁÛÉÁ²`¶ NS¬s ¹¸¶V²R¶ÌÁ A \|ms gRiÑÁÛÉÁ²`¶
¾»½[µj¶ @µ³j¶NSLji xqsLi»R½NRPª«sVV ¿Á[¸¶R Vª«sÌÁ¸R¶VV©«sV. ª«sVLji¸R¶VV {qs*¸R¶V
Date µ³R¶X dsNRPLRißá ¿ÁÌýÁµR¶V.)

For OFFFICE USE Signature

O.R. ( ) Drawing and Disbursing Officer (If DDO is
not gazetted, it should be countersigned
by next Gazetted Officer and Self
Attestation is not acceptable)

x¤¦Ü[µy
Designation

NSLSùÌÁ¸R¶V ª«sVVúµR¶
Office Seal

Supdt. DIO

Please visit our Website : [Link] for further information and guidelines

APTF (257) PALNADU