<Postal code><Address><Borrower's last name><Borrower's first name><Loan Code>[For Applications and Inquiries]
Saitama Prefectural Council of Social Welfare,
Repayment and Exemption of COVID-19 Special Loan Section[Telephone Number] 050-2018-1839[Office hours] Weekdays 9:00-17:00
https://www.fukushi-saitama.or.jp/site/problem_33.html

Notice to borrowers under deferment of repayment ofCOVID-19 Special Loan
Applications for extension of repayment deferment will be accepted from those who haveconcerns about repayment after the repayment deferment period. The overview is as follows,and those who wish to apply are requested to do so.
Persons eligible thistime(Persons who meet
all three of thecriteria on the right)

Borrower under repayment deferment
Borrowers who have concerns about repayment after the repayment
deferment period

Where to apply

Saitama Prefectural Council of Social Welfare, Repayment andExemption of COVID-19 Special Loan Section

Required documents
at the time ofapplication

A. Application Form for Repayment Deferment Extension and Living
Situation Confirmation Sheet
B. Certificate of residence listing all members of the household (issuedwithin the last 3 months)
C. Taxation certificate of the Borrower and the head of household for thefiscal year 2024 or documents showing income for the last 3 months.
* Please submit a copy of your disability certificate or any otherdocument that shows the physical and mental condition of theBorrower and his/her family members.

Flow up to theextension ofdeferment ofrepayment① Borrowers who wish to apply for an extension of deferment ofrepayment should send the required documents in a self-addressedenvelope to Saitama Prefectural CSW by mail.
② Borrowers are contacted by the municipal CSW and conduct thefirst interview, etc.
③ Saitama Prefectural CSW will decide whether or not to extend thedeferment of repayment based on the results of interviews, etc. at themunicipal CSW, and notify the Borrower.

Flow after theextension ofdeferment ofrepayment④ Borrowers receive support from the municipal CSW for consultationand for monitoring of their living situation.
⑤ Borrowers arrange a second interview with the municipal CSW(approximately 6 months after the application is received) * Inprinciple, the second interview is face-to-face.
⑥ Based on the results of interviews, etc. at the municipal CSW, Saitama
Prefectural CSW will decide whether to (a) forgive repayment, (b)terminate the deferment of repayment (start repayment), or (c) reextend the deferment of repayment, and notify the Borrower

Persons who have
moved out of theprefecture

If you have moved from Saitama Prefecture to another prefecture andwish to extend the deferment period for repayment, please first contact
the Saitama Prefectural CSW Repayment and Exemption of COVID-19
Special Loan Section (050-2018-1839).

Points to remember

If you have all of the required documents, you will be contacted by theMunicipal CSW within 2 to 3 weeks of your application, so please
schedule a date and time for the interview, etc.
As a result of an interview at the municipal CSW, the municipal CSW
may introduce you to a self-reliance support consultation agency inorder to assist you in rebuilding your life.
In the event that you do not respond to the contact from the Municipal
CSW, etc. and the second interview, etc. cannot be conducted, thedeferment of repayment may be cancelled.

* Please also refer to the "Flow of application of extension of deferment of repayment"on the reverse side of this page.

Required documents A
Application Form for Repayment Deferment Extension and Living Situation Confirmation
Sheet* If you need a copy of the application, please make a copy before mailing* Barcode

1. About the Borrower
Application date//

Loan Code<Loan Code>Name* Signature* Signature(To be written by the applicant)Loan applicant

Current
address
A phone number that is easy toreach you on during the day
A time when it is easy to contact you
on weekdaysPlease describe the situation you
are having trouble with(Free answer)

NameRelationship

YouLiabilities

The situation of the household of the applicant for consultation

LenderS/years old)EL
※Please write the language you
usually use

Interviews about living situation in person / Interviews about living situation by telephone

Age Name of employer / School (grade)//]

Occupation

Health condition(monthly)(Situation of injury, illness, disability, etc.)

Monthly repayment Remaining years

Household expenditure per monthAmount

Income2. Not receivingBorrowed amountHousehold income per month)

HeiseiAroundAM/PM* Please fill in with a time between 9:00 AM and 5:00 PM.

1. Receiving [FromTotal(PMA

2. Borrower’s household status

Details

2023/(Please circle your preference for the methodof conducting the first interview, etc.

Yes･NoShowa

Language* To be answered by foreign
nationals onlyLanguage※Please fill in the blank only forforeign nationals〒WelfareTaishoDate of birthMale/Female

Furigana

Details

Arrears situation
YES/NOyen

YES/NOyenYES/NO

yen

Confirmation of household income
Salaries and Pensions, Benefits and Allowances Provided* Check the appropriate box

Amountyen

Food expenses

yen

yen

Utility costs

yen

yen

Phone/Internet costs

yen□ Work (salary) income□ Unemployment
insuranceyen□ Old-age pension/
survivor's pension□ Disability pension

Housing expenses (rent)yen□ Child-care allowance□ Child-rearingallowance

yen Debt and other repayments

yen

yen

Other

yen

yen

Totalyen□ Accident and sickness benefits□ Other ()* I agree to the following items and apply for an extension of the repayment deferment period (If you agree, please sign your name above)･ I agree that the required documents, including this application, will be provided to the CSW of the municipality where I currently reside.
･ I agree that after this application form, etc. is provided to the Municipal CSW, I will be contacted by the Municipal CSW and that I will receive monitoring support by the Municipal CSW, including interviews, etc.
･ I agree to conduct at least two interviews after submitting an application for an extension of the repayment deferment period.
･ I agree to work in good faith to rebuild my life during the period of monitoring support.
･ I agree that I will not take any action such as forcing the Municipal CSW to write according to my will with regard to the written opinions submitted to Saitama Prefecture CSW.
･ 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, informationfrom government and other public offices pertaining to my, or my household members', membership in an organized 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 constituentorganizations) to engage in violent unlawful acts, etc. collectively or habitually."]･ I agree that the personal information provided in the form will be provided to related organizations such as self-reliance support consultation agencies within the scope necessary for this program.
･ I agree that Saitama CSW may refer to and receive my personal information from the Japan National Council of Social Welfare, other prefectural CSW, municipal CSW, local governments,
public employment security offices, self-reliance consultation support organizations, household financial improvement support organizations, and other related organizations to the extent
necessary for this program.

Documents required for application for extension of defermentof repayment
Required documents for application to Saitama Prefectural
Council of Social Welfare
Item No.

ARequired documents

Self-checkcolumnApplication Form for Repayment Deferment Extension and Living
Situation Confirmation Sheet□Certificate of Residence* Be sure to send a certificate of residence that meets the following
conditions.
･ It bears the name of the head of the household
B･ It states that it is "certified to be an authentic copy of the original certificate ofresidence for all members of the household".
･ It does not include the applicant's Individual Number (MyNumber).
･ It was issued within the last 3 months
Taxation certificate for FY 2024 (Borrower and the head of household) or
document showing income for the last 3 months (Borrower and the headof household)･ Pay stubs (copy) or other documents showing income status
C･ For pension recipients, a copy of the notice of pension payment or a copy ofa bankbook showing payment* If you have no current income and can provide proof of unemployment,
please do so.
* In addition, please submit the following documents, if any･ If any member of the household has a Mental Health and Welfare Handbook or PhysicallyHandicapped Persons Handbook, or Rehabilitation Certificate, a copy of the handbook, a doctor'scertificate or other documents that show the physical and mental condition and living situation of theBorrower and his/her family, such as various handbooks, notices of receipt of various allowances andbenefits, etc.

□□

･ Please send the required documents to Saitama Prefectural CSW by mailwith the enclosed return envelope.
･ The required documents will be provided to your municipal CSW after
Saitama Prefectural CSW confirms that they are complete and correct.
･ You will be contacted by the Municipal CSW within 2 to 3 weeks of yourapplication, so please schedule a date and time for the interview, etc.
･ If you do not understand Japanese, please contact the call center.
Phone number: 050-2018-1839
Open/close: Weekdays 9:00-17:00
URL: https://www.fukushi-saitama.or.jp/site/problem_33.html

Flow of application of extension ofdeferment of repayment
1. Borrowers who wish to apply for an extension of deferment of
repayment should send the required documents in a selfaddressed envelope to Saitama Prefectural CSW by mail.
Required documents
A. Application Form for Repayment Deferment Extension and Living Situation
Confirmation Sheet
B. Resident tax taxation certificate of the Borrower and the head of household
for the fiscal year 2024 or documents showing income for the last 3months.
C. Certificate of residence listing all members of the household (issued within
the last 3 months)
Please submit a copy of your disability certificate or any other document that shows the physicaland mental condition of the Borrower and his/her family members.

2. Borrowers are contacted by the municipal CSW and conduct thefirst interview, etc.
In the first interview, etc., please explain the following main points･ Reasons and circumstances for current repayment difficulties･ During the repayment deferment period, is the borrower himself/herself making
sincere efforts to rebuild his/her life, such as by aiming to increase income orreview expenses?
･ Borrower's and family's physical and mental condition and living situation･ Is it possible to rebuild his/her life by working, increasing income, improving myhousehold finances, etc.?

3. Saitama Prefectural CSW will decide whether or not to extend thedeferment of repayment based on the results of interviews, etc. at
the municipal CSW, and notify the Borrower.

4. Borrowers receive support from the municipal CSW for consultationand for monitoring of their living situation.

5. Borrowers arrange a second interview with the municipal CSW (6months after the application is received)* In principle, the second interview is face-to-face.
Please explain the following main points based on the first interview, etc.
･ Has the reason for the difficulty in repayment been resolved with support from themunicipal CSW?
･ During the repayment deferment period, is the borrower himself/herself making
sincere efforts to rebuild his/her life, such as by aiming to increase income orreview expenses?
･ The physical and mental condition and living conditions of the Borrower andhis/her family between the first interview and the second interview･ Is it possible to rebuild his/her life by working, increasing income, improving myhousehold finances, etc.?

6. Based on the results of interviews, etc. at the municipal CSW,
Saitama Prefectural CSW will decide whether to (a) forgive
repayment, (b) terminate the deferment of repayment (startrepayment), or (c) re-extend the deferment of repayment, andnotify the Borrower