Example（Submission）Parent→School→Boardof Education

For Children

Form 1YYYY20○○MM○DD○

Application for Higashihiroshima City School Meals
To the Mayor, Higashihiroshima City
〒７３９－８６０１

Parent, etc.
（Person with duty to pay） Address○-○ Saijo Sakae-machi, Higashihiroshima City
Furigana

さいじょう

Name

SaijoTelephone（Homeたろう印○TaroMobile

Other（））

０９０－１１１１－２２２２Details of the child who will receive the school meals

I wish for my child to receive school means, and as such I hereby apply for school meals
according to the stipulations of Clause 3 of the Ordinance Regarding the Collection of Fees for
Higashihiroshima City School Meals, and having consented to the Points to Note and Items ofConsent below.
ElementarySchool
Higashihiroshima City Municipal
Saijo
School△JuniorGradename
Nenchu ・High
NenchoSchoolKindergarten
Date ofDate:○○YYYY○MM ○DDbirthSex
Furigana
さいじょうじろう

Saijo

NameAddress① 〒M ・Jiro

②
Same
as
parent/guardian－Write in ①,or circle ②

FromStart date
Paymentmethod☑

F

YYYY

Bank account transferMMDD□ Payment slip

【Points to Note】・This application form will continue to be used from while your child is in a municipal
elementary school in Higashihiroshima until he/she graduates from a municipal juniorhigh school (or until he/she moves to a school other than a municipal school). For a childat a municipal kindergarten, this form will continue to be used until the child leaves thekindergarten.
・If you continue to be in arrears with payments, and you appear not to have any intentionof paying the debts, legal measures may be taken against you.
【Items of Consent】
・I consent that, if I am in arrears with school meal fees, Higashihiroshima City may
investigate and make use of information about me (the person with the duty to pay theschool meal fees) and the members of my household living off the same source(s) ofhousehold income, including items recorded in the Basic Resident Register, status oftaxation with regard to municipal tax, etc., as far as is necessary for the purposes ofcredit management of school meal fees.
・I consent that, if I am in arrears with school meal fees, Higashihiroshima City and myExample（Submission）Parent→School→Boardof Education

For Children
child's school may share the information they have in order to determine details of theamount of my arrears and the reason for my non-payment, and the circumstances of myhousehold.

Offer Regarding the Collection of School Meal Fees from Child Allowance Payments
To the Mayor, Higashihiroshima City
Regarding the following,☑ I consent□ I do not consent

If I am in arrears with the payment of school meal fees, according to Section 1 or Section 2 of Clause 21of the Child Allowance Law, I offer to allow the school meal fees to be paid from the Child Allowancepayments I receive from the Mayor of Higashihiroshima Cityon isthea dateof paymentof theChild fromThis
consent
form fortransfer
Allowance in question.
benefits(ChildAllowance)
you are in
Further, unless I withdraw this offer, my payments of school
meal fees
will bemet from whenmy Childarrears with payments. You will normally
Allowance payments, as specified in this offer.
Date: 20○○YYYY ○ MM ○ DD
Person receiving the Child Allowance payments
NameAddress

Saijo Taropay school meal fees by bank transfer orby using payment slips.
Name of child

Saijo Jiro○-○ Saijo Sakae-machi, Higashihiroshima City