Note: This form is for your reference only.

英語第２号様式
証 明書 番 号

号

罹 災 証 明 書 交 付 申 請 書
Disaster Certificate Application Form
年月
YearMonthWard Director

区長 Hiroshima City,

広島市

日Day

申 請 者 Applicant
住 所（ 所 在 地 ）Address (Location)
氏 名（ 名 称 、代 表 者 の 役 職 名 及 び 氏 名 並 び に 代 表 者 印 の 押 印 ）Full Name (Name, representative’s position and name and representative’s seal)
電 話 番 号 Telephone No.
（）−

罹災世帯主等との関係 Relationship to thehouseholder of the disaster-hit building, etc.

次のとおり、罹災証明書の交付を申請します。
I hereby make an application for a Disaster Certificate as follows.
罹災世帯主【住所(所在地)】【氏名(名称)】（所有者・借家人等）(Address (Location))(Full Name (Name))
Householder of disaster-hitbuilding(owner/tenant, etc.)
【提出先】
【必要数】
証明必要数及び提出先(Numberrequired)(To whom they will be presented)
Number of certificatesrequired and to whom they
will be presented
通 Copies
罹災建物の場所
Location ofdisaster-hit building
罹災建物
Disaster-hit building
罹災建物との関係
Relationship todisaster-hit building
罹災原因
Cause of disaster

広島市区 Hiroshima CityWard（マンション等の場合は名称を記載）(If disaster-hit building is a
condominium or apartment building, please write its name)□住家Residence□非住家 Non-residence building（□所有者 Owner）□借家人等 Tenant, etc.

（例：XXXX 年 XX 月 XX 日に発生した地震 ）(Ex: Earthquake which struck on xxDay /xx Month / xxYear)

罹災状況
Condition of damage （例：北側の壁に亀裂が発生した。）(Ex: Crack(s) in wall on the northside.)
Photograph(s) of condition of damage□罹災状況の写真
添付書類□罹災建物の位置図 Map showing location of damaged building
Attached documents/materials□その他 Other（）
備 考
Comment・罹災証明書は、民事上の権利義務関係効力を有するものではありません。
・「記入上の留意点」を参照してください。
-The Disaster Certificate does not hold any authority regarding rights
related to civil law disputes.
-Please refer to [Points to note when filling in the form]

Note: This form is for your reference only.

※太 枠欄 の中 に記 入し てください。
*Please fill in the section
within the thick lines.
受付印 Seal

注１ 個人が申請する場合は、本人確認と住所確認ができる書類（運転免許証等）の準備をしておいてください。
注２ 法人等の従業員等が申請する場合は、従業員等であることを確認できる書類（社員証等）の準備をしておいてください。
注３ 居住していないが所有している罹災
建物についての申請の場合や法人等の所在地と罹災建物の場所が異なる場合などは、所有権等を確認できる書類の準備をしておいてください。
注４ 任意代理人が申請する場合は、委任状に記入してください。

英語

Note 1. When an individual is making anapplication, he/she should prepare
documents which can identify theindividual and the individual’s address(e.g. driver’s license)
Note 2. If an employee of a legal entity(company, etc.) is making an application,
he/she should prepare documents(company ID card) which can verify they
are an employee.
Note 3. Regarding the application for a
Disaster Certificate for an owned
non-residence disaster-hit building, or if
a legal entity’s (registered) address isdifferent from that of the disaster-hit
building, documents verifying
ownership are required.
Note 4. If a mandatary(repreresentative) is making anapplication, a mandate from must be
filled in.

Note: This form is for your reference only.

英語

Points to note when filling in the form
1. The applicant should fill in the information within the thick lined section of the Disaster
Certificate Application Form.
2. If an individual is making an application, the applicant should fill in their address, fullname and telephone number in the applicant’s section and their relationship to thehouseholder of the disaster-hit building (owner, tenant, etc.) as in 3 below.
If a registered legal entity (registered company, school, hospital, etc.) is making anapplication, the applicant should fill in the address, name and the representative’sposition and name as well as the telephone number. The representative’s seal should beattached in the seal section. (There is no need to state the relationship to thehouseholder of the disaster-hit building (owner, tenant, etc.).)If a mandatary (representative) is making an application, the Mandate From below mustbe filled in. However, if the mandatary is a family member or an employee of theregistered legal entity (registered company, etc.), the mandate form need not be filled in.
3. In the [Householder of disaster-hit building (owner/tenant, etc.)] section, fill in the nameand address of the householder who resides (resided) in the disaster-hit building. Ifmaking an application for a building which is owned but not resided in the name andaddress of the owner, etc. should be filled in.
If the applicant is a legal entity (registered company, etc.), the address and name of thelegal entity (registered company, etc.) must be filled in.
4. In the [Number of certificates required and to whom they will be presented] section, fillin the number of Disaster Certificates required and to whom they will be presented to.
If there are multiple places (offices, etc.) to whom the forms must be presented to, fill in
the name of each and the number of forms required.
5. In the [Location of disaster-hit building] section, write the location of disaster-hitbuilding (if it is a condominium (apartment building) etc., write the name of thebuilding).
If there are a number of buildings involved, a Disaster Certificate Application From foreach build must be filling in.
6. In the [Disaster-hit building] section, place a ✔ mark in the Residence box (if thebuilding is presently being used as a place to live in), and place a ✔ mark in theNon-residence building (if it is a building for a purpose other than living in).
If it is a Non-residence building, please state what kind of building (hospital, shrine,etc.) it is. Also, if a person is living continuously in a non-residence building, please makea note of this.
7. In the [Relationship to disaster-hit building] section, regarding the disaster-hit building
write the relationship to the building as in 3 above, householder of the disaster-hitbuilding (owner, tenant, etc.). Place a ✔ mark in the relevant box: Owner / Tenant, etc.
8. In the [Cause of disaster] section, write the cause of the disaster.
Ex. 1: Heavy rainfall on XX Year XX Month XX DayEx. 2: Earthquake occurred on XX Year XX Month XX Day
9. In the [Condition of damage] section, write details of the damage caused to the building.
Ex. 1: Cracks in northern wall
Ex. 2: Flooded to above floor level on first floor
10. In the [Attached documents/materials] section, place a ✔ mark in the relevant box forthe attached documents/materials attached. If there are other documents/materials
attached, please write their names. There may be some documents that you will need toattached, but if for some reason it is difficult to present them, please consult with thestaff.

Note: This form is for your reference only.

英語

委任状
Mandate Form
代理人の住所

Representative’s address

代理人の氏名

Representative’s full name

私は、上記の者を代理人と定め、次の建物について、罹災証明書の交付申請に関する権限を委任します。
I designate the above stated person as a representative, and mandate the said
person with authority to apply for the issuance of a Disaster Certificate.
罹災建物の場所
Location ofdisaster-hit building
罹災建物
Disaster-hit building

広島市区 Hiroshima City,Ward□住家Residence□非住家 Non-residence building（年 Year月 Month）
日 Day

罹災世帯主等の住所 Householder, etc. of disaster-hit building’s address

罹災世帯主等の氏名Householder, etc. of disaster-hit building’s full name印 Seal