SPCSW No.
//〈郵便番号〉〈住所〉〈借受人姓〉〈借受人名〉〈貸付コード〉〈バーコード〉Saitama Prefectural Council of Social Welfare
Repayment and Exemption of COVID-19 Special Loan Section

Special loans such as emergency small amount funds due to the impact of the COVID-19 pandemic

Information Regarding Repayment Forgiveness and Repayment

Notification of Exemption and Repayment
This is to inform you of the upcoming repayment forgiveness and repayment of emergency small amount funds
and other special loans for COVID-19 that are provided by the Council.
Please review the following documents regarding repayment forgiveness and repayment carefully.

Details

1. DocumentsInformation
sent this time(encloseditems)
Regarding
Repayment
Forgiveness and Repayment(1)(2)
Notificationof loans
ExemptionandRepayment
Application form for repayment
Specialeligible forrepayment
forgivenessforgiveness (booklet)

画像

画像

(3)
Return envelope

画像* An example of how to fill out the form is on
P.4.

Please read the booklet (2) carefully and confirm the procedures for
repayment forgiveness and repayment.
2. For Inquiries
Saitama Prefectural Council of Social Welfare,
Repayment and Exemption of COVID-19 Special Loan Section[Telephone Number]
050-2018-1839[Reception Time]
Weekdays 9:00 am to 5:00 pm
https://www.fukushi-saitama.or.jp/site/problem_33.html*Available in several languages for foreigners[Requests]･ We do not accept documents directly. Please refrain from bringing your documents to this office.
･ It may be difficult to get through by phone immediately after receiving this notice.
･ Documents will not be returned once submitted.

(Form 1-1)

Application Form for Repayment Forgiveness for Special Loans for Comprehensive Support Fund
Comprehensive Support Fund (Re-lending)* Please fill in all fields in the bold frame.
Type of fundBorrower'sName
Loan amountReason for
exemption
application
Householdstatus* Pleaseindicate yourhousehold
status byadding a ☑ toany one ofthe following

Required
documents* Prepare thedocuments
and add a ☑
to the box

Comprehensive Support Fund (Re-lending)≪差し込み≫
Amount of exemption
applied for≪差し込み≫

Maximum amount of repayment forgivenessfor the type of fund in question

I am exempt from both per-capita and per-income inhabitants tax.
I (the borrower) am currently the head of thehousehold
Someone other than the borrower is currently
the head of the household, and the current
head of the household was in a separate
household from the borrower at the time of loanapplication
A person other than the borrower is currently
the head of the household, but I (the borrower)
cannot obtain an income certificate for the headof household as I have evacuated due todomestic violence, etc.
All three documents below are required

If none of the statuses on the left applies tothe borrower

All three documents below are required
Exemption application form (this document)
An original of the certificate of residence
showing all members of the current household(Bearing the name of the head of thehousehold and relationship to the head of thehousehold)Originals of the borrower’s and the head of
the household’s 2024 certificate of
inhabitants tax exemption * Which states that theExemption application form (this document)
An original of the certificate of residence
showing all members of the current household(Bearing the name of the head of the household
and relationship to the head of the household)An original of the borrower’s 2024 certificate of
inhabitants tax exemption * Which states that theborrower is exempt from both the "per-capita" and "perincome" portions of inhabitants tax

borrower is exempt from both the "per-capita" and"per-income" portions of inhabitants tax

To the Chair of the Saitama Prefectural Council of Social Welfare
I agree to the following six items and hereby apply for an exemption.

① If repayment forgiveness is approved, I agree to my personal information being provided to a self-reliance support
consultation agency for the purpose of utilizing it in the performance of the organization's duties.
② I agree to my personal information being provided to third parties to the extent necessary for this program.
③ I agree that the Saitama Prefectural Council of Social Welfare may query the National Council of Social Welfare, otherprefectural councils of social welfare, municipal councils of social welfare, local governments, public employment
security offices, self-reliance support consultation agencies, household financial improvement support organizations,and other related organizations to receive my personal information to the extent necessary for this program.
④ Neither I nor any members of my household are members of an organized crime group. I agree that the Saitama
Prefectural Council of Social Welfare may request, as necessary, information from government and other public offices
pertaining to my, or my household members', membership in an organized crime group.(Organized crime group isdefined in Article 2, Item 2 of the "Act on Prevention of Unjust Acts by Organized Crime Group Members," as "Anorganization that is likely to encourage its members (including members of the organization's constituent organizations)to engage in violent unlawful acts, etc. collectively or habitually.")⑤ I agree that if repayment forgiveness is rejected as a result of the screening, the reason for the rejection will not bedisclosed.
⑥ I have not changed the head of household for the purpose of receiving repayment forgiveness. I also agree that therepayment forgiveness will be revoked if any of the information in this application is found to be false or if any of therequirements for repayment forgiveness are found to be not applicable after the decision for repayment forgivenesshas been made.
//* Write the date you filled out this form * Please sign your name exactly as it appears above.
Borrower’s Name (Signature)
Telephone Number:* Provide a telephone number where you can be reached during the day.
* The information below is not to be filled by the applicant.
*Fund CodeLoan CodeSX≪差し込み≫

Receipt No.

Saitama Prefectural CSW
Reception//

バーコード≪差し込み≫
資金コード≪差し込み≫