（Format type 1-2）

Temporary Loan Emergency Funds Exemption Application FormEmergency Small Amount Fund/General Support (First Payment)(Administration use)

*Answer within bold box

Borrower’s Name
Repayment Exemption
Application Amount

Total amount of temporary emergency funds for the reason stated below

Repayment Exemption
Application Reason①
If multiple answers aretrue, select longest
existing reason ☑

Persons receiving public assistance for protection oflivelihood

Repayment Exemption
Application Reason②
No answer required for
those eligible for Reason①

Persons with outstanding payment amount of 12months or more + the amount of non-payment isincreasing despite repayments being made ininstallments or small amounts + it is an elderly only
household, a disabled household, or a single parenthousehold, etc. where the residential tax based on
income is exempted.

Persons with mental disability certificate (grade 1) or aphysical disability certificate (grade 1 or 2)

Exemption fromrepayment of total
amount applicable

Exemption fromrepayment of amount of
overdue payments
amountApplication to Chairperson of the Kyoto Prefectural Council of Social Welfare[Consent Form] Before submitting this application, carefully read the following points ① to ⑥ and check (☑)theboxes to consent.

① If exemption from repayment under this special scheme is confirmed, I agree to provide my personal
information to the independence counseling and support organization to be used in line with saidorganization's work.

② I agree to provide the personal information submitted to a third party to the extent necessary for theexecution of this scheme.

③ I agree to the council of social welfare using, to the extent necessary for this scheme, my personal
information with the National Council of Social Welfare, other prefectural councils of social welfare,municipal councils of social welfare, local governments, public employment security offices, andindependence counselling and support organizations. I also agree to the sharing of my personal
information to related organizations such as household management improvement support
organizations.

④ I, nor my household members are gang members. I agree to comply with any request from the Council ofSocial Welfare to provide information on whether I or my household member is a member of anorganized crime group to be submitted to public offices, etc. (Organized crime groups are definedaccording to article 2 section 2 of ‘Act on Prevention of Unjust Acts by Organized Crime Group Members’
as groups that may encourage the practice of violent and unlawful acts, etc.)⑤ I acknowledge that no reason may be given in the case that my application for exemption is rejected.
⑥ The head of household has not been changed to apply for exemption from repayment, and I agree to theexemption from repayment will being canceled if it is found that the information provided in thisapplication is false or does not meet the requirements for exemption from repayment even after the resultof application has been notified.
Year:Month:Day:*Please write the date of filling out this application form.

Borrower’s name (Signature):Tel. No.:――

*Contactable during daytime*Do not fill out below*●Fund CodeLoan CodeApplication No.

Kyoto Pref. Social Welfare
Council Application
YearMonthDay

Local Municipality Social
Welfare Application
YearMonthDay