4 Identification, etc.

Personal Information Disclosure Request Form

Please check the box below and send the required documents without omission.
(Date)HIMARAYA Co.,Ltd.
Legal & Compliance Team□ In case of the person in questiona. Documents verifying the claimant's identity (with the claimant's name and current address)

Name□Driver's license…① □Health insurance card…② □Basic resident register card…③□Pension book…④□Passport…⑤□Residence card, special permanent resident certificate,or alien registration certificate deemed as these documents…⑥
Please send us a copy of any of (1) through (5). In case of (6), photocopies are not acceptable.
(*Original copy within 3 months)

Address□ In the case of a legal representative (A-1, A-2)
□Legal representatives (minors)

Phone□Legal representative (adult interviewee)a. Documents verifying the claimant's identity (with the claimant's name and current address)

The following is a request for disclosure of personal information held by your company inaccordance with the Personal Information Protection Law.

1 Please describe specifically the retained personal information for which you are requesting
disclosure.（Name, Address, Telephone number, etc.）□Driver's license…① □Health insurance card…② □Basic resident register card…③□Pension book…④□Passport…⑤□Residence card, special permanent resident certificate,or alien registration certificate deemed as these documents…⑥
Please send us a copy of any of (1) through (5). In case of (6), photocopies are not acceptable.
(*Original copy within 3 months)
b. Situation of the person in question, etc.
(a) Status of the individual□ Minor（Date of birth(Month/Year) :/） □ Adult ward(b) Name of the person(c) Address or residence of the personc. Documents confirming eligibility for claim (certified documents must be less than 3 months old)
□Copy of family register (A-1: for minors) □Certificate of registered matters (A-2: for adult wards)
d. Documents to verify the identity of the legal representative□Driver's license…①□Pension book…④□Health insurance card…② □Basic resident register card…③□Passport…⑤*Please send us a copy of any of (1) through (5).

□ In the case of a proxy by power of attorney (B-1)
a. Documents verifying the claimant's identity (with the claimant's name and current address)

2 Method of conducting disclosure
Due to the need to strictly handle identity verification, disclosure is limited to disclosure
by mail (general registered mail) only.

Please send us a copy of any of (1) through (5). In case of (6), photocopies are not acceptable.
(*Original copy within 3 months)
b. Document certifying that the power of attorney has been granted (both the letter of attorney andthe seal registration certificate are required)

3 Commission(HIMARAYA use column)

Commission(520 yen per case)
Please enclose postage
stamps for the amount.

□Driver's license…① □Health insurance card…② □Basic resident register card…③□Pension book…④□Passport…⑤□Residence card, special permanent resident
certificate, or alien registration certificate deemed as these documents…⑥

Date ofreceipt(HIMARAYA use column)

Recipient(Request authorizationseal)□Power of Attorney (with the claimant's personal seal)
person making the request)□Certificate of seal impression (for thec. Documents to verify the identity of the authorized representative□Driver's license…① □Health insurance card…② □Basic resident register card…③□Pension book…④□Passport…⑤*Please send us a copy of any of (1) through (5).