3/13/2019 Pradhan Mantri Shram-Yogi Maandhan - (PM-SYM)

असंग ठत कामगार के लए पशन योजना

APPLICATION-CUM-MANDATE FORM (UIN 512G312V01)

PERSONAL DETAILS
Shram Yogi Pension Account Number 700015063898 Periodicity of Contribution: Monthly

Name of the Subscriber

(as on Aadhar Card)
Asif Ali

Date of Birth 13-04-1987 Age 31 Gender Male  

Occupation Electronic electrical goods repairs Category OBC  

Marital Status Married Name of Spouse aayan  

Nominee Relation with

Name of Nominee Aayan Subscriber
Son  

Additional Details
DOB 05-10-2017 Guardian’s Name Asif Ali  
(in case of Minor Nominee )

I am not member of ESIC/EPFO/NPS or income-tax assessee No  

I am also remitting the Monthly Subscriber for assured monthly pension

INR 110.00 Rs. 3000/-
Contribution amount of

Declaration & Authorization by Subscribers

I ful l the prescribed eligibility criteria under PM-SYM. I have read and understood the terms and conditions of the scheme. I hereby agree to the same. I declare that the information
furnished by me is true and correct to the best of my knowledge and belief.Further I do not hold any pre-existing account under PM-SYM. I understand that I am fully liable for
submission of any false or incorrect information or documents given above. I have read / been explained and I have understood PM-SYM guidelines.
I hereby authorize Ministry of Labour and Employment/LIC/CSC SPV/ to use My Aadhaar details for PM-SYM and authenticate my identity through the Aadhaar Authentication
System in accordance with the provisions of the Aadhaar (Targeted Delivery of Financial and Other Subsidies, bene ts & Services) Act 2016 and Rules and Regulations noti ed there
under.I have been given to understand that my information submitted to herewith, shall not be used for any purpose other than mentioned above or as per requirement of law.

Date : 13-03-2019 Signature/Thumb Impression* of subsciber

Place : ----------------- (*LTI in case of Male/RTI in case of Female)

NOTE SUBSCRIBER IS NOT REQUIRE TO PAY ANY ADITIONAL FEE OR CHARGE FOR ENROLLMENT OTHER THAN FIRST CONTRIBUTION
This is subscription cum computer generated acknowledgement and does not require signature. Shram Yogi Pension Card received.
िजनक मेहनत दे श का आधार, उनक पशन का सपना साकार

UMRN                                         Date 13-03-2019

 
Tick (✓)
Sponsor Bank Code 259 Utility Code NACH00000000022197
 CREATE (✓)
 
 MODIFY I/We hereby authorize LIFE INSURANCE CORPORATION OF INDIA to debit (tick ✓)
 CANCEL
Bank A/C Number 0297101017706

with Bank Canara Bank IFSC CNRB0000297 or MICR                  

an amount of Rupees Two Thousand Four Hundred Only   2400/-

monthly Qtly H-Yrly Yrly As & when

FREQUENCY DEBIT TYPE Fixed Amount Maximum Amount
presented
Reference 1 700015063898 Phone No. 9977540002
Reference 2 Email ID mailme.asifali@gmail.com
I agree for the debit of mandate processing charges by the bank whom I am authorizing to debit my account as per latest schedule of charges published by the bank.
PERIOD
From 13-03-2019 Signature Primary Account Holder   Signature of Account holder   Signature of Account holder
To                
or Until Cancelled 1 . Name as in bank records   2 . Name as in bank records   3 . Name as in bank records

This is to con rm that the declaration has been carefully read, understood & made by me/us. I am authorising the user entity/ corporate to debit my account,
based on the instruction as agreed and signed by me. I have understood that I am authorized to cancel/amend this mandate by appropriately communicationg the

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3/13/2019 Pradhan Mantri Shram-Yogi Maandhan - (PM-SYM)
cancellation/ amendment request to the User entity/corporate or the bank where I have authorized the debit.

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