Address◎Contact
Children & Families Department , Childcare Support Division【TEL】0761 (24) 8057
【FAX】0761 (24) 4312
【E-Mail】shien@city.komatsu.lg.jp【Phone Reception Hours】 Mon-Fri 9：00 ～17：00

Name ofHousehold HeadForm No.

Notice on Payment of Inflation-Support Cash Handout for Resident Tax-Exempt Households(Top-up for Households With Children)
Based on your tax payment status in 2023, you are eligible for the Inflation-Support Cash Handout for Resident
Tax-Exempt Households, as detailed below.
(This notice is sent to registered heads of household as of 1 Dec 2023)

1. Recipient
Name

Date of BirthAddress
2. Eligible

Name

ChildrenDate of Birth1(y/m/d):

年

月日

2(y/m/d):

年

月日

3(y/m/d):

年

月日

4(y/m/d):

年

月日

5(y/m/d):

年

月日

6(y/m/d):

年

月日

7(y/m/d):

年

月日

8

(y/m/d):

年

月日※List all children (up to 18 years old, born from 2 Apr 2005 onwards) who are part of the same household, as of 1 Dec 2023

2. Amount
No. of eligible children

人 Total payment

円

4. Payment Method (as a general rule, will be transferred to account of household head)
To be paid via Bank transfer

To be transferred on 26 March 2024.

RecipientBank**********

Account

Account type********************
Account No.

**********

Account Holder**********

The account previously used to receive the Emergency Cash Handout for Emergency Cash Handout for Resident Tax-Exempt
Households is detailed above. If you wish to use a different account, please submit the application form on the reverse page,by 18 March 2024 (delivery deadline) *submission not required if no change.
If you wish to decline this handout, please contact the Childcare Support Division.

5. Important Notes
・If it is discovered after payment of the handout that you are no longer eligible, due to modications to tax
declaration etc., you may be asked to refund the handout.
・Beware of scammers requesting for bank transfer or personal information in the name of this handout.

✂Cut here✂

Request Form for Bank Account Change

Please fill in below if you wish for transfer to a different bank account (if the bank account indicated on the front page has been terminated etc.)□In place of the bank account indicated in the notice, I wish for transfer to the following account.

【Recipient Account】※After filling in the following blanks, please attach verfication documents for the specified bank account.
Account Number
Account Name (Katakana)Bank Name
Branch NameType
※align to the right

1.銀行 4.信連 7.信漁連

本･支店

2.金庫 5.農協

本･支所

1 Savings

3.信組 6.漁協出張所

2 Current

Bank code

Branch code

Japan Post Bank
If using Japan Post Bank account, fill in the code (記号) and number(番号)printed on the upper left corner of the inside cover of the passbook, or on thecash card.

※Write as printed in your passbook

Passbook code

Passbook number

Account Name (Katakana)fill in the ※ blank if there are6 digits※align to the right※Write as printed in your passbook

10※Proxy Verification Form
Please fill in below if the bank account belongs to someone other than the household head.

【If a proxy (representative) is receiving handout on your behalf】

Furigana
Proxy NameP

Relationship withapplicant
1. Same householdrox

明治・大正・昭和・平成

２．Legal proxy
３．※Othersy

Proxy's Address

Proxy's Birthdate（(y)

年 (m) 月 (d) 日）

Phone no. contactable in the day
Name ofI appoint the above as my proxy, and entrust them to receive my emergency cash handout
on my behalf.

（）

Signature（or stamped name）

householdhead印※ "Others" refers to relatives or other persons caring for the household head on a regular basis, as specially recognized by the mayor.
※If you are requesting transfer to a different account from indicated on the front page, or for a proxy to receive on your behalf, you are required to submit your (oryour proxy's) personal ID for verification. *A copy of one of the following: My Number Card (with photo), driver's license, passport, health insurance card.