2023//
SPCSW No. 90<Postal code><Address><Borrower's last name><Borrower's first name><Loan Code>Hiroki Yamaguchi, Chairman
Saitama Prefectural Council of Social Welfare(Official seal omitted)

Notice of Repayment Start Date of Special Loans for Emergency Small Amount Funds, etc.

This is to notify you that repayment of the above loan will commence as follows.
〇 Loan status and amount to be repaid (Repayment balance)
Fund Name<Emergency small amount or Initial
comprehensive loan>

Loan CodeBorrower's Name
Loan amount<Loan Code><Name><Loan amount>Amount already repaid<Amount already repaid>

Outstanding amount tobe repaid〇 Repayment period, etc.
Deferral period (the period until repayment commences)
Repayment period

Until <20From <20//> to <20////>>

Number of repayments

Monthly/Yearly (XX installments)

Repayment amount perinstallment

First installment onwards (X00,000 yen); Final installment (X00,000 yen)

〇 Repayment method
Repayment method<Direct debit/convenience store payment>

In the case of direct debit, monthly debits will be made on the 13th of each month under the name "RKS（トクレイ". (Or the next business day if the 13th falls on a Saturday, Sunday or holiday)

サイタマケン[Special loans for which an application for repayment forgiveness can be made for FY 2023]• Even if you were "not exempt from inhabitants tax" in FY 2021 and FY 2022, you can apply for repayment forgiveness if you meetthe requirements.
Please read the enclosed booklet "Special loans for which repayment forgiveness will be applied in FY 2023" carefully forthe requirements and details.
[For Applications and Inquiries]

Saitama Prefectural Council of Social Welfare, Repayment and Exemption of COVID-19
Special Loan Section[Phone number] 050-2018-1839 [Office Hours] Weekdays 9:00-17:00 https://www.fukushi-saitama.or.jp/site/problem_33.html

(Form 1-1)

Application Form for Repayment Forgiveness for Special Loansfor Emergency Small Amount Funds, etc.
For Emergency Small Loan Funds<Council Use Only>* Please fill in all fields in the bold frame.
Type of fund

Emergency small amount funds

Borrower's Name

Taro Saitama

Loan amountReason for exemption
application

100,000 yen

Maximum amount of repayment forgiveness for thetype of fund in question

Amount of exemption
applied for

I am exempt from both per-capita and per-income inhabitants tax.
 I (the borrower) am currently the head of thehousehold

Household status* Please indicate yourhousehold status byadding a  to any oneof the following

 Someone other than the borrower is currently
the head of the household, and the current headof the household was in a separate from theborrower at the time of loan application

 If none of the statuses on the left applies to theborrower I (the borrower) cannot obtain an income
certificate for the head of household as I haveevacuated due to domestic violence, etc. (aperson other than the borrower is currently thehead of the household).

(1) (All three documents below are required)

Required documents(2) (All three documents below are required)(1)-1: Exemption application form (this document)(2)-1: Exemption application form (this document)(1)-2: A copy of the certificate of residence showing all
members of the current household(Bearing the name of the head of the household andrelationship to the head of the household)(2)-2: A copy of the certificate of residence showing all
members of the current household(Bearing the name of the head of the household andrelationship to the head of the household)(1)-3: Borrower's taxation certificate for FY 2023
(Certificate showing that the borrower is exempt frominhabitants tax)(2)-3: Taxation certificates of the borrower and thehead of the household for FY 2023
(Certificate showing that the borrower is exempt frominhabitants tax)

* Those who are exempt from both per-capita and perincome inhabitants tax are eligible for forgiveness* Those who are exempt from both per-capita and perincome inhabitants tax are eligible for forgivenessTo 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 purposeof 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, other prefectural councils of socialwelfare, 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 forthis 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 anorganized crime group. (Organized crime group is defined in Article 2, Item 2 of the "Act on Prevention of Unjust Acts by Organized Crime Group
Members," as "An organization 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 reject as a result of the screening, the reason for the rejection will not be disclosed.
(6) I have not changed the head of household for the purpose of receiving repayment forgiveness. I also agree that the repayment forgiveness will be
revoked if any of the information in this application is found to be false or if any of the requirements for repayment forgiveness are found to be notapplicable after the decision for repayment forgiveness has been made.

20//* Please sign your name as printed above* Write the date you filled out this form

Borrower’s Name (Signature)
Telephone Number−* The information below is not to be filled by the applicant
Fund CodeLoan Code
Receipt No.
*KA1234567−* Provide a telephone number where you can be reached during the day.

Saitama Prefectural CSW Reception//

Entry example[Please write clearly and strongly with a ballpoint pen without going outside the frame]

Do not fill in
Refer to P.2 of the booklet

Refer to P.3 of the booklet

Refer to theapplicable pagein the booklet
and check thebox(es)Please confirm
all items(1) through (6)･ Date filled out･ Signature･ Telephone
numberPlease do notforget to fill thesein

Do not fill inPlease check the box properly (clearly) with a✓.
Good example

Bad examplesetc.