Ver 1.

NATIONAL PENSION SYSTEM (NPS)

Exit from National Pension System Due to Death

Claim ID Acknowledgement No Affix

recent colour
To, photograph of
NPS Trust. 3.5 cm × 2.5 cm size /
Passport size
Sir/Madam,

I hereby apply for the payment of the accumulated pension wealth in NPS
Tier-I account of as per the relevant provisions of the PFRDA (Exits and withdrawals
under NPS) Regulations, 2015 as amended.

Tier II:- The entire accumulated pension wealth in Tier II account would be paid along with lumpsum withdrawal of
Tier I account.
I herewith give below the necessary details: Signature / Thumb Impression*
*In case of female right thumb Impression and in case of male left thumb Impression may be taken. of the Claimant / Guardian

Sr.No Particular Remarks

Section A - Details of the Subscriber & Claimant

Subscriber Sector* 1. Govt. Sector
2. All India citizens/corporate
3. NPS Lite / GDS
1. Organisation Name* (PAO/DTO/CHO/NLAO Name)

2. PRAN*
3. Name of the Subscriber* First Middle Last
4. Subscriber Gender* Male Female
5. Maiden Name (In case of female married Subscriber) First Middle Last
6. Father's Name* First Middle Last
7. Marital Status of the Subscriber* Married Unmarried/Others
Spouse Name of the Subscriber (only if subscriber was married & First Middle Last
8.
Spouse is alive)
9. Spouse Gender (only if subscriber was married & Spouse is alive) Male Female
10. Date of Death of the Subscriber* DD / MM / YYYY
11. Date of Birth of the Subscriber (As in PRAN Card)* DD / MM / YYYY
12. Name of the Claimant* First Middle Last
13. Aadhar/VID
14. PAN of claimant*
15. CKYC Number
16. Are you a Politically Exposed Person (PEP)* Yes No
17. Are you related to a Politically Exposed Person (PEP)* Yes No
Do you have any history of conviction under any criminal proceedings
in India or abroad?* Yes No
18.
If Yes, please provide details
Address :

19. Contact details of claimant* Mobile No* : +91

Alternate Phone No :
Email Id* :
Date of Birth of Claimant (Only in case of minor) : DD / MM / YYYY
Relationship With Subscriber :
Percentage Share:
Guardian Name (Only in case of minor) : First Middle Last
Guardian DOB (Only in case of minor)
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Section B - Claimant’s Bank Details - (Please refer instruction No. 6)

20. Bank Account Number* :
21. Bank Name*
Bank Branch Name and Address : The monthly pension and lump sum
22. amount would be deposited into this account and hence fill in all the
details carefully.*
IFSC Code (attach a cancelled cheque leaf or copy of bank passbook
23.
/bank certificate containing IFSC code)*
Fields marked with * are mandatory.

Section C - Claimant Withdrawal Details - (Please refer instruction No. 7)

In event of death after / before superannuation or attaining 60 / 65 years of age
a) Would you like to withdraw full amount (if less than or equal to 2 lakh for Government Subscriber) Yes No
or
b) Would you like to have normal Withdrawal (Lump sum & Annuity Withdrawal) # Yes No
# Please provide the Percentage of corpus that you wish to opt for lump sum withdrawals and purchase of annuity:
# Claimant can allocate any percentage of amounts to be invested in annuity scheme. (not applicable in case of Government Sector)
% of corpus opted for lump sum withdrawal Percentage of corpus opted for purchase of Total (100%)
(Max 20% - for Government Subscriber) annuity (Min 80%- for Government Subscriber)

Section D - Claimant’s Annuity Details - (Please refer instruction No. 11 & 12) (Not to be filled in case of complete withdrawal)
Select Annuity Service Provider (please tick one of the below options as per your choice)
Bajaj Allianz Life Insurance Co. Ltd. Canara HSBC Oriental Bank of Commerce Life Insurance Co. Ltd.
HDFC Life Insurance Co. Ltd. ICICI Prudential Life Insurance Co Ltd.
IndiaFirst Life Insurance Co. Ltd. Kotak Mahindra Life Insurance Co. Ltd.
Life Insurance Corporation of India Max Life Insurance Co. Ltd.
SBI Life Insurance Co. Ltd. Star Union Dai-ichi Life Insurance Co. Ltd.
Tata AIA Life Insurance Co. Ltd.
Select Annuity Scheme (please tick one of the below options as per your choice)
Annuity for Life
Annuity for Life with return of purchase price on death
Annuity payable for life with 100% annuity payable to spouse on death of annuitant
Annuity payable for life with 100% annuity payable to spouse on death of annuitant with return on purchase of annuity
NPS-Family Income option (Default annuity)(Mandatory For Government Sector Subscriber)
Other (Please Specify)
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

*Signature/Thumb Impression of the Claimant

Date : DD / MM / YYYY (Signature of Guardian in case the Claimant is a minor)

*In case of female right thumb Impression and in case of male left thumb Impression may be taken

Section E - Subscriber’s Family Member Details* (To be filled in case claimant has selected NPS-Family Income option)
Family Member Details for providing annuity as chosen by the subscriber.

Sr.No Details Full 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.
$
Mandatory in case Claimant opts for NPS-Family Income option.
Declaration by the Claimant
I hereby declare and state that all the personal details provided by me in the form as 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 or delays that may arise due to provision of incorrect details including details
pertaining to bank account by me. Further, I authorize the National Pension System Trust(NPST)/ CRA to share informations pertaining to my withdrawal
application with the Annuity Service Providers for facilitating the purchase of annuity in applicable cases as is required under NPS.

*Signature/Thumb Impression of the Claimant

Date : DD / MM / YYYY (Signature of Guardian in case the Claimant is a minor)
*In case of female right thumb Impression and in case of male left thumb Impression may be taken.
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Declaration by the Proposer: (Not to be filled in case of complete withdrawal)
I hereby declare that the foregoing statements and informations 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
premiums
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 state 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 the final annuity amount would be subject to the actual corpus value to be utilised for 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 / Left thumb Impression of the

Signature of the witness Proposer

Affix a recent self signed

photograph

Name and Address of witness:

Place:

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 I/We state that the product details, contents of
documents to the proposer in language, that he/she/they undertook that this form and relevant documents have been
he/she/they have understood the same and agree to abide by the terms and conditions of the resulting fully explained to me/us and that I/We have fully
policy and have affixed his/her/their signature/thumb impression on the proposal form in my presence. understood them. I/We certify that the replies in
the proposal form have been recorded as per
Signature of the person the information provided by me/us.
making the declaration

Name & Address

Signature / Left thumb Impression of the

Proposer

Place Date: DD / MM / YYYY

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Section F - 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 Claimant with the originals and authorized this application for processing of the subject claim of
the claimant. It is certified that 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 Claimant
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 / Claimant is certified as provided in the withdrawal form above. The name of Subscriber / Claimant as mentioned on the
withdrawal form has been verified and can be accepted as final.
4. It is also certified that this office has not paid/received any family pension to the legal heir(s)/nominee(s) of the deceased subscriber and we don’t have
any objection for release of accumulated pension wealth to his/her claimant. (Applicable for government Sector subscribers only)
5. The bank account details of the Claimant as provided in bank details section have been checked and verified and the same can be accepted for
payment.

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

DDO/POP-SP/NLCC Registration Number

Designation of the Authorised Person : DDO/POP-SP/NLCC Office Name:

Date D D / M M / Y Y Y Y

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

DTO/PAO/POP/ Aggregator Registration Number
Designation of the Authorised Person : DTO/PAO/POP/ Aggregator Office Name:

Date D D / M M / Y Y Y Y

[As per Regulation 3(c) of PFRDA (Exits and Withdrawals) under Regulations, 2015]
(To be filled in case of complete withdrawal)
Request cum under taking form for withdrawal of total pension wealth due to death of Subscriber and/or where the total pension wealth is equal to
or less than Rs. 2,00, 000/- in case of government sector Subscriber

I being a nominee/legal heir/guardian of

minor nominee or minor heir of the deceased subscriber apply for the payment of the accumulated pension wealth of the deceased subscriber under the NPS
and do hereby solemnly affirm and declare as under:
1. 
That I have been nominated as a nominee/is legal heir in respect of PRAN of deceased subscriber
Sh/Smt/Ku __________________________, under NPS. .
2  hat since the total amount receivable as benefits upon exit from NPS is Rs
T which is less than/equal to the limit of
Rs. 2,00,000/-, I/we understand that I am eligible to opt for withdrawal of the total pension wealth in the individual pension account of the deceased
subscriber as per the provisions of the PFRDA (Exits and withdrawls from NPS) Regulations, 2015 as amended.
3. I/we accordingly hereby opt to withdraw complete pension wealth lying in the aforesaid PRAN account, as admissible and being the full and final benefits
receivable by me/us.
I also understand that with the aforesaid withdrawal, I or my family members shall not be entitled to receive any other or further benefits including annuities
under the National Pension System (NPS) as stipulated under PFRDA (Exits and Withdrawals under the National Pension System) Regulations 2015, as
amended.

Date :
*Signature/Thumb Impression of the Claimant
Place : (Signature of Guardian in case the Claimant is a minor)
*In case of female right thumb Impression and in case of male left thumb Impression may be taken.

Date D D / M M / Y Y Y Y

Rubber Stamp of the DDO/POP-SP/NLCC Signature of the DDO/POP-SP/NLCC Registration No. of DDO/POP-SP /NLCC

Date D D / M M / Y Y Y Y

Rubber Stamp of the Signature of the Registration No. of

DTO/PAO/POP/Aggregator DTO/PAO/POP/Aggregator DTO/PAO/POP/ Aggregator

*In case of female right thumb Impression and in case of male left thumb Impression may be taken.
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INSTRUCTIONS FOR FILLING UP FORM

This application should be filled by the nominee/claimant seeking to withdraw pension wealth benefits due to death
of the NPS subscriber
General Instructions: 9.  List of documents acceptable as Proof Identity and Address for exit under
NPS (for all variants):-
1. 
As per amendments made under Prevention of Money-Laundering
Sl. Proof of Identity (Copy of Proof of Address (Copy of
(Maintenance of Records) Second Amendment Rules, 2017, withdrawal
No. any one of the given below any one of the given below
of benefits from NPS Account will not be allowed if Aadhaar and PAN of documents) documents)
the claimant is not provided at the time of initiation of online withdrawal
a Passport issued by Government Passport issued by Government
request (Aadhaar not mandatory till Hon’ble supreme court order)
of India. of India.
2. The claimant has to submit the physical form to the subscriber’s nodal b Ration Card with Photograph. Ration card with photograph and
office. The nodal office has to compulsorily submit the form in online residential address.
mode only. Physical form submitted to CRA will not be processed
c Bank pass book or Certificate Bank Pass book or certificate
3. All the columns in the form should be filled with black ink pen without any with Photograph with photograph and residential
address.
overwriting.
d Voters Identity card with Voters Identity card with
4. Fields marked with (*) are mandatory.
photograph and residential photograph and residential
5. Correct postal address, including the pin code should be provided. address. address.

e Valid Driving license with Valid Driving license with

6. Documents to be enclosed with withdrawal application form:
photograph. photograph and residential
Original Death Certificate of deceased subscriber. In case of NPS
i.  address.
Lite and Government Sector subscriber copy of death certificate duly f PAN Card issued by income tax Letter from any recognized public
attested by Nodal Office is required. department. authority at the level of Gazetted
officer like District Magistrate,
Copy of the Address proof of nominee/claimant attested by the
ii.  Divisional Commissioner, BDO,
Nodal Office in support of the address provided on the withdrawal Tehsildar, Mandal Revenue
form. The address given on the withdrawal form should match with Officer, Judical Magistrate etc.
address present on the address proof. g Certificate of identify with Certificate of address with
photograph signed by a Member photograph signed by a Member
Copy of the Identity proof of nominee/claimant attested by the
iii. 
of Parliament or Member of of Parliament or member of
Nodal Office. Legislative Assembly. Legislative Assembly.
Copy of PRAN card (Not required in case of Government Sector
iv.  h Aadhar Card/letter issued by Aadhar Card/letter issued by
Subscriber)If Copy of PRAN Card is not available, print out of Unique identification Authority of Unique identification Authority
ePRAN or submit a duly notarized Affidavit as to the reasons of non- India. of India. Clearly showing the
address.
submission of the PRAN card.

Cancelled cheque (containing Nominee/claimant’s Name, Bank

v.  i Job Cards issued by NREGA duly Job Cards issued by NREGA duly
signed by an Officer of the State
Account Number and IFS Code) or Bank Certificate/Bank Passbook Government. signed by an Officer
Containing Name, Bank Account Number and IFSC code, for direct
credit or electronic transfer. of the State Government.

7. Withdrawal preference: j Photo Identity card issued by Latest Electricity/Water bill in the
Defence, Paramilitary and Police name of the subscriber / Claimant
i. 
The entire accumulated NPS wealth in the individual pension Departments. and showing the address (Less
account of the deceased subscriber shall be paid as lump sum to the than 6 months old).
nominee(s)/legal heir(s). k Ex-Service Man Card issued Latest Telephone bill in the name
by Ministry of Defence to their of the subscriber/ Claimant and
ii. Claimant is not required to fill Section D, Section E and Declaration employees. showing the address (less than 6
by Proposer if Claimant opts for Complete Withdrawal or Claimant months old).
opts for Lump Sum Withdrawal only.
l Photo credit Card. Latest property/house Tax
iii. In case nominee is a minor, the form shall be filled up by the guardian. Receipt (not more than one year
old).
iv. The nominee or family member of the deceased subscriber have the
option to purchase any of the annuities available with the empanelled m – Existing Valid registered lease
agreement of the house on stamp
Annuity Service Providers (ASPs).
paper (in case agreement of the
v. If the nomination is not registered by the deceased subscriber before house on stamp paper (in case of
rented/leased accommodation).
his/her death, the accumulated pension wealth shall be paid to the
family members on the basis of the legal heir certificate issued by n Identity card issued by The identity card/document with
the Revenue Authorities of the State concerned or the Succession Central / State government address, issued by any of the
and its Departments, Statuary following:
Certificate issued by a court of competent jurisdiction.
Regulatory Authorities, Public
8. The nominee(s)/legal heir(s) need to provide his/her complete bank details Sector Undertakings, Scheduled Central/State Government
Commercial Banks, Public and its Departments, Statuary/
like name of the bank, branch, complete address of branch, account type Financial Institutions, Colleges Regulatory Authorities, Public
and IFSC otherwise the form may get rejected by CRA. Please make affiliated to Universities and Sector Undertakings, Schedules
sure there is no cutting or overwriting in this section. The lump sum payment Professional Bodies such as ICAI, Commercial Banks, Public
shall be directly credited to the bank account of the nominee(s)/legal ICWAI, ICSI, Bar Council etc. Financial Institution for their
Employees.
heir(s)thorough electronic mode of payment.
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10. 
The Nodal Office after verifying the completeness of the Withdrawal time and purchase price is returned to the nominee after the death
Form and supporting documents in all respects after signature/thumb of the spouse If the spouse predeceases the annuitant, payment
impression of nominee/ legal heir and declaration and attestation of the of annuity will cease after the death of the annuitant and purchase
authorised person at Nodal Office shall send at below mentioned address price is paid to the nominee.
for processing of the withdrawal claim for record keeping within 90 days Note:
from the date of approval: Please note the exit from NPS and purchase of annuity from empanelled
ASP are two separate processes. It is mandatory for subscribers
NPS Claims Processing Cell
to purchase annuity scheme from Annuity Service Providers (ASP)
Central Record Keeping Agency, empanelled by PFRDA. Post receipt of the form by ASP and completely
NSDL e-Governance Infrastructure Ltd, satisfying themselves of completeness of the form and KYC requirements,
1st Floor, Times Tower, annuity shall be issued to subscriber (applicable to government sector
Kamala Mills Compound, subscriber).
Senapati Bapat Marg, Lower Parel,
The more details on the availability of particular annuity scheme with an
Mumbai - 400013.
ASP and annuity quotes etc. are available on the CRA’s website as per
11. Annuity Service Providers link below:

There are 11 Annuity Service Providers empanelled by PFRDA for www.npscra.nsdl.co.in/annuity-service-providers.php
providing the annuity services to NPS subscribers as per the list provided ASP Scheme Details and Annuity Selection Matrix may change. Please
below (Name of the ASPs are given in an alphabetical order). visit CRA website before filling Annuity Details. The list of empanelment
Name of the ASPs, minimum age and minimum corpus required for of ASPs may undergo changes depending upon new empanelment of
annuity purchase ASPs by PFRDA from time to time.

Other than Default

For Government Sector Subscriber only
Annuity Service Provider Name Default Annuity
Annuity 12. As per regulation 3 (c), at least 80% out of the total accumulated pension
Minimum Minimum Minimum Minimum wealth of the subscriber shall be mandatorily utilised for purchase of
Age Corpus Age Corpus
annuity and the Annuity contract shall provide for annuity for life of the
Bajaj Allianz Life Insurance Co.
NA NA 37 25,000 spouse of the subscriber (if any) with the provision of return of purchase
Ltd.
Canara HSBC Oriental Bank of price. Further details of the annuity scheme are described under
45 2,25,000 45 2,25,000
Commerce Life Insurance Co. Ltd. Regulation 3(c) provides that the annuity contract shall provide annuity
Any Any for life of the spouse of the subscriber (if any) with provision for return of
HDFC Life Insurance Co. Ltd. 30 20
Amount Amount
purchase price of the annuity and upon the demise of such spouse be
ICICI Prudential Life Insurance Any Any
30 30 re-issued to the family members in the order specified hereunder at the
Co Ltd. Amount Amount
IndiaFirst Life Insurance Co. Ltd. 40 10,000 40 10,000 premium rate prevalent at the time of purchase of the annuity, utilizing
Kotak Mahindra Life Insurance the purchase price required to be returned under the contract (until all the
NA NA 45 2,24,000
Co. Ltd. members given below are covered):
Life Insurance Corporation of India 20 50,000 30 50,000
(a) living dependent mother of the deceased subscriber ;
Max Life Insurance Co. Ltd. NA NA 50 2,50,000
(b) living dependent father of the deceased subscriber .
SBI Life Insurance Co. Ltd. 18 50,000 18 50,000
Star Union Dai-ichi Life Insurance
After the coverage of all such members, the purchase price shall be
45 1,00,000 45 1,00,000
Co. Ltd. returned to the surviving children of the subscriber and in absence of
Tata AIA Life Insurance Co. Ltd. NA NA 45 2,24,200 children, to the legal heirs of the subscriber as applicable.

The following are the variants that are available in India and with most of 13. The balance of the accumulated amount shall be paid as lump sum to the
the ASPs. Subscriber needs to select any of the below mentioned option nominee(s) or legal heirs, as the case may be, of such subscriber.
on the withdrawal form: 14. If the accumulated pension wealth in the permanent retirement account
1. 
Annuity for life - On death of the annuitant, payment of annuity of the subscriber at the time of his death is equal to or less than two lakh
rupees, the nominee/legal heirs, has the option to withdraw the entire
ceases.
accumulated pension wealth by submitting request come undertaking
2. 
Annuity for life with return of purchase price on death - On death
form without purchase of annuity. Upon exercise of this option the right of
of the annuitant, payment of annuity ceases and the purchase price is
the family members to receive any pension or other amounts under the
returned to the nominee
National Pension System shall extinguish.
3. 
Annuity payable for life with 100% annuity payable to spouse on
15. The nominee/claimant claiming the lump sum amount needs to provide
death of annuitant - On death of the annuitant, annuity is paid to the
his/her complete bank details like name of the bank, branch, complete
spouse during his/her life time. If the spouse predeceases the annuitant, address of branch, account type and IFSC otherwise the form may
payment of annuity will cease after the death of the annuitant. get rejected by CRA. Please make sure there is no cutting attempt on
4. Annuity payable for life with 100% annuity payable to spouse and overwriting in this section. The lump sum payment shall be directly
on death of annuitant with return on purchase of annuity - On credited to the bank account of the nominee/claimant through electronic
death of the annuitant, annuity is paid to the spouse during his/her life mode of payment.