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Form 103-GD Page 1 National Pension System NPS Withdrawal of Accumulated Pension Wealth by Claimant due to the death of the subscriber Please fill all the details in CAPITAL LETTERS in BLACK INK only. /- Rupees. Only from settlement of National Pension System account of late Shri/Smt. with PRAN Number Affix 1 Rupee Revenue Stamp and sign across Page 4 Requirements submitted along with this form Yes / No Original PRAN Card In the absence of PRAN card notarized affidavit Death certificate in original issued by local authorities Photo ID Address proof of the Claimant Date of birth proof of claimant Legal heir certificate Certified copy of family member s certificate issued by Executive Magistrate Account Number and IFS Code or Bank Discharge Certificate from the employer in case claim is lodged through a POP/POP-SP Note PFRDA reserves the right to call for additional requirements if needed for establishing a valid claim under National Pension System. DECLARATION AUTHORIZATION I hereby declare that the information given on this death claim application form is true and complete to the best of my knowledge and belief. I hereby declare and agree that any personal information collected or held by the National Pension System NPS whether contained in this application or otherwise obtained is provided andmay be held used and disclosed by the Company to individuals/organisations associated with the NPS or any selected third party within or outside of India for the purposes of processing this application. Witness Signature Name of the Witness Name of Claimant in block letters family name first Address of Witness Date // Date // ACKNOWLEDGMENT RECEIPT To be filled by PAO/DTO/POP/POP-SP Received from PRAN Number PAO/DTO/POP/POP-SP Office Name Received at Date Time Page 5 INSTRUCTIONS FOR FILLING UP THE FORM All the columns in the form should be filled with black ink pen without any overwriting Fields marked with are mandatory. This application should be filled by If a valid nomination subsists By the Nominee s if the nominee s is/are minor s guardian of the minor s If no nomination subsists By the family members family includes posthumous child if any except major sons and married daughters whose husbands are live of the deceased family member duly supported by a list of surviving family members furnished by Executive Magistrate indicating complete particulars such as name relationship with the deceased member in case of parents whether dependent or not age marital status. Also if any family member is minor by the guardian of the minor. 3. If both 1 2 above are not applicable By legal heir s duly supported by a legal heir certificate from the appropriate sate authority. 4. In case of multiple claimants separate forms need to be filled and submitted* FOR OFFICE PURPOSE ONLY-NOT TO BE FILLED IN BY THE CLAIMANTS Date DD/MM/YYYY DDO Registration No* Acknowledgement Number Generated by CRA PAO/DTO/POP/POP-SP Registration No* Receipt Number issued by receiving office Entered By Date Verified By Date Sir/Madam I/We being a nominee s /legal heir s /guardian of minor nominee s or minor heir s of the deceased subscriber apply for the payment of the accumulated pension wealth of the deceased subscriber under the NPSfor both Tier-I / Tier-II please tick as applicable.

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