About Disclosure Request by Postal Mail
Items Necessary for Disclosure Request
1. Credit Information Disclosure Request Form
2. Two Identification Documents
3. Handling Charge*JPY 1,500 worth of “Disclosure ticket” (Available at convenience stores Booking Code: 0262294)
or “fixed- amount postal money order (Teigaku Kogawase Shousho).”
1. Credit Information Disclosure Request Form
■Refer to the “How to Fill Out a Credit Information Disclosure Request Form” sample and provide yourinformation completely.
・We cannot accept a request form lacking any information required for the disclosure.
・We will report the information on which your “katakana-name, date of birth, and phone number or driver’s
license number” matched to the credit data registered.
・For the date of birth, check the checkbox corresponding to the era name.
・As for the phone number, please provide all of the numbers you may have used for credit contract and other occasions,in the order that you would like to receive information for.
If the Phone numbers do not correspond to the credit data registered, we cannot make disclosure.

*If you have registered your “self-declaration information” with us, please write the registered phone number in <Phone Number 1> field.
*If you are registered as a person having “self-restraint of loans” with Japan Financial Services Association and Personal Credit Information Centerof Japanese Bankers Association, please write the registered phone number in <Phone Number 1> field.

2. Identification Documents■ Enclose any two of the following 11 items with your request.

1. Driver’s license or driving record certificate［Copy of both sides］* 1
2. My Number Card（Individual Number Card）［Copy of the side with photo only］
3. Passport [Copy including the address field]
4. Health insurance card [Copy including address field] * 2
5. Basic Resident Registration card with Photo[Copy of both sides] * 1

6. Pension Book [Copy including address field] * 2
7. Handicapped Person’s Book [Copy including address and date of birth fields]
8. Residence card or special permanent resident certificate [Copy of both sides] * 1[Original or copy within three months from issuance date]
9. Certificate of residence [without legal domicile and individual number] * 2
10. Family register or its abstract(Removal record and supplement are not applicable.) * 2
11. Seal certificate (with current address)* 1: If there is no change in address or other information, front side only suffice. (Any amendments to the information stated must have been madeat a governmental institution.)* 2: If your legal domicile, individual number, basic pension number and/or health insurance code number are shown, please paint them out.

[Note: Regarding Identification Documents]
・At least one of the identification documents you send us must carry your current address provided in your credit
information disclosure request (delivery address).
・Documents must be issued by an administrative agency and must be valid at the time of your request.
・When you make a photocopy, make sure that your name, date of birth, address and expiration date are clearlyvisible.
*”Notification Card” for your individual number is not valid as an identification document.
*If you send us any copy of a document carrying your individual number, we will immediately mask and then shred it sothat it will not be restored.
*Documents submitted will not be returned.

F52023.9

3. Handling Charge for Disclosure: JPY 1,500 (tax included)
・Please choose your method of payment from “disclosure ticket” (available at convenience stores) or“fixed-amount postal money order”.
・Please send valid tickets/money order (expiration date is 6 months after the date of issue).

■Disclosure ticket (Available at convenience stores)

Booking Code:0262294

・Please purchase a “disclosure ticket” using a multimedia station at 7-Eleven/FamilyMart storefront or Loppi at
Lawson/Ministop storefront. (Booking code is the same for all convenience stores.)・A disclosure fee of 1,500 yen plus an issuance fee will be displayed in the menu.
・Please note that handling charges are non-refundable.
・If you need a receipt, please contact JTB HTA Sales Center (0570-016088). (CIC will not issue any receipt.)■1,500 JPY Fixed-amount postal money order certificate
・”Fixed-amount postal money order certificate” is available at Japan Post Bank.
・An issuance fee prescribed by Japan Postal Bank is added to the face value.
(*) Depends on the issuance fee for fixed-amount postal money order defined by Japan Post Bank.

(JPY 200 per each money order as of April 2023)
Issuance fee varies depending on the combination of face values of “fixed-amount postal money order certificates.”
Example: When purchasing JPY 1,500 worth certificates, if you purchase one JPY 1,000 certificate and one JPY 500
certificate, you will have to pay JPY 1,900 comprised of (1,000+200) + (500+200).
・Do not write anything on the “fixed-amount postal money order certificate”.

4. Delivery of your Credit Information Disclosure Report■ Your Credit Information Disclosure Report will be sent to the current address you provided in the disclosure
request by “simplified registration (Kan-i Kakitome)” and “Confidential(Shinten) delivery”.

*We may omit the building name in your address.
*It will generally take 7-10 days from your request until dispatch.

5. Optional Items(1) Disclosure by maiden name/byname (with additional charge)
If you request disclosure related to your maiden name or other name, fill out the “Request Disclosure by Maiden
Name/Byname” field (kanji and katakana-name is required), and we will add information for that name.
・Handling charge of JPY 1,500 per name is required.
・Enclose a document (such as family register) to confirm the maiden name/byname.

①If you are paying handling charge by “disclosure tickets” for more than one request, please first
select a ticket including delivery (e.g. simplified registration), and from there on, select tickets for “additional name”.
Example 1: For your current family name and two former family names (total 3 names)⇒Disclosure ticket for simplified registration + Disclosure ticket for additional name ×2
Example 2: For your current family name and two former family names (total 3 names) by express delivery⇒Disclosure ticket for express mail + Disclosure ticket for additional name ×2② We cannot accept your disclosure request regarding your maiden name or other names unless charges
corresponding to the number of names and identification documents for such names are enclosed.
③If you would like to receive disclosure only by your maiden name/byname, check the box for "Request
Disclosure by Maiden Name/Byname only.”④ If no name is provided in the “Request Disclosure by Maiden Name/Byname” field, we will only disclose yourcurrent name even if you have checked any option in the “Disclosure by Maiden Name/Byname” fields.
(2) Delivery by express mail and/or personal delivery (with additional fee)
Additional charge applies to “Express (sokutatsu)” or “Personal (hon-nin gentei uketori yubin)” postal delivery.
Check the “Postal Delivery Options” checkbox of the credit information disclosure request form to select the desireddelivery option. Enclose a “Disclosure ticket” or “fixed-amount postal money order” including theadditional delivery charge corresponding to the selected option.

F52023.9Desired Delivery Option

Disclosure Ticket
Booking Code: 0262294(Available at convenience stores)

No option (simplified registration)(JPY 1,500+issuance fee)
Express mail(JPY 250+JPY 1,500+issuance fee)
Personal delivery (special type)(JPY 300+JPY 1,500+issuance fee)
Express mail + Personal Delivery (special type)(JPY 550+JPY 1,500+issuance fee)

Fixed-Amount Postal Money
Order

JPY 1,650

JPY 1,500+ issuance fee

JPY 1,925

JPY 1,750+ issuance fee

JPY 1,980

JPY 1,800+ issuance fee

JPY 2,255

JPY 2,050+ issuance fee①If enough “Disclosure ticket” or “fixed-amount postal money order” for the total amount including delivery option
is not enclosed, we will send by “simplified registration” and “confidential” delivery, even if “express” or “personaldelivery” is selected.
②Please understand that, if a “Disclosure ticket” or “fixes-amount postal money order” covering postal delivery option
are enclosed but no checkbox is checked, priority will be given to handling by “personal delivery.”③If the delivery option charge is enclosed in the form other than “disclosure ticket” or “fixed-amount postal moneyorder” (such as postal stamp, cash or revenue stamp), we will send the credit information disclosure report by“simplified registration” and “confidential” delivery and return the postal stamp etc. to you.
④If you send excessive amount as postal delivery option charge, we will refund in the form of postal stamp of fixedamount postal money order.

6. Inquiry regarding Disclosure Procedure
Phone: 0570‐666‐414 (only in Japanese)
Mon-Fri 10:00 ～16:00 (Closed on Saturdays, Sundays, national holidays and new year holidays)

7. Where to Send the Request Form

■ Enclose items 1-3 described at the top of this document and send to the [Address] below.

*We ask you to pay the postage for sending your request form. Please affix a postal stamp when sending.
We will not accept any request if the charges are not fully paid.

*We cannot accept the request if it is incomplete, including the cases such as “the address shown on the request form
is different from that of your identification document”, “not all required documents and charges are enclosed”, or“identification documents are expired.”
All documents will be returned in such cases.
*No cancellation is possible once we accept the request.
*We recommend you send your request by a method with a delivery record, such as simplified registration.

[Address]

Cut along the dotted line for shipping address.
〒160‐8375 Cut along the broken line
and paste on the envelope.
東京都新宿区西新宿 1‐23‐7
新宿ファーストウエスト 15 階
株式会社 シー・アイ・シー
郵送開示センター 行

F52023.9

■■ Please Check again before Sending Your Request!! ■■*We cannot accept the request if it is incomplete.

In such a case, we will return all the documents you have sent.
Please check again without fail if you have all the required items below before submission.
Points to check

Required Items* Check □ to confirm.
□

1. CIC Credit Information
Disclosure Request Form□

Have you filled out all required fields correctly?
Have you provided all of your phone numbers (mobile or home) you had used for credit
contract and other occasions, in the order of priority in your search?

*We will report the information when your katakana-name, date of birth, and phone number ordriver’s license number correspond to our registered data.

□

Have you enclosed two out of the following 11 identification documents?

*“Notification Card” for your individual number is not valid as identification document.
Does at least one of your identification documents carry the same address asprovided in your request form?

2. Two pieces of Identification
Documents

3. Handling charge
worth JPY 1,500□⇒ As we will send the disclosure report to the address we can confirm with the identification
documents, at least one of them should carry the same address as provided in the request
form.
*If you would like the report to be delivered by express/personal delivery, please see the bottomof this table.

□

Have you painted out your [legal domicile, individual number, basic pension
number and health insurance code number] on your identification documents?

□

Are the identification documents currently valid and not expired?

□Is the “disclosure ticket” or the “fixed-amount postal money order” issued within
6 months?

*Do not write anything on the fixed-amount postal money order certificate.
*See below if you request disclosure by your maiden name/byname.

◆ [If you request disclosure by your maiden name/byname] (Disclosure process for your maiden name)
Provide your maiden name/byname in the [Request Disclosure by Maiden Name/Byname] field (katakana name is required) of
the request form.
⇒When you request disclosure by more than two names such as your current family name and your maiden name,please enclose JPY 1,500 worth “disclosure ticket” or “fixed-amount postal money order” per name.
Example: For current family name plus maiden name, JPY 3,000 is required as handling charge.
⇒If you request disclosure by your maiden name only, check the “Request Disclosure by Maiden Name only.” checkbox.
⇒Also, additional documents (such as your family register) to confirm your maiden name etc. are required.
◆ [If you request express/personal delivery] (Process for postal delivery options)
Please check □ for “Postal Delivery Options” in the request form and enclose a “disclosure ticket” or “ fixed-amount postal
money order” corresponding to the total amount of the handling charge and the fee for the selected delivery option.

F52023.9Identification Documents
1. Driver’s license or driving record certificate［Copy of both sides］* 1
2. My Number Card（Individual Number Card）［Copy of the side with photo only］
3. Passport [Copy including the address field]
4. Health insurance card [Copy including address field] * 2
5. Basic Resident Registration card with photo[Copy of both sides] * 1

6. Pension Book [Copy including address field] * 2
7. Handicapped Person’s Book [Copy including address and date of birthfields]
8. Residence card or special permanent resident certificate [Copy of bothsides] * 1[Original or copy within three months from issuance date]
9. Certificate of residence [without legal domicile and individual number]*2
10. Family register or its abstract (Removal record and supplement are notapplicable.) *2
11. Seal certificate (with current address)*1: If there is no change in address or other information, front side only suffice. (Any amendments to the information stated must have been
made at a governmental institution.)*2: If your legal domicile, individual number, basic pension number and/or health insurance code number are shown, please paint them out.

F52023.9Annex※ Please read carefully.
※ Please note that your personal information provided for the disclosure request will behandled as described below. Please read before filling out the request form.

Provisions Related to the Handling of Personal Information
Section 1. (Purpose of Use of the Collected Personal Information)
We collect personal information in this disclosure request for the following purposes:
Purpose of Use
1

Personal Information Used for the Purpose

Identifying the person and responding to the request regarding
disclosure of credit information upon your request

2

Responding to your inquiry

3

Studying statistic about registration, reference and disclosure ofcredit information

Your personal information provided in our
specific forms, such as your name, date ofbirth, postal code, address, and phone number.

Section 2. (Retention and Maintenance)
We correctly maintain your personal information and retain it with appropriate care of your privacy.
We retain personal information for up to two months after acquisition and destroy it immediately once the retention period
expires.
Section 3. (Transfer to a Third Party)
We will not transfer personal information to any third party unless:
1 The requester agrees with it,
2 It is required by law,
3 It is necessary in order to protect someone’s life, body or property, and it is difficult to obtain consent from the requester,
4 We are obliged to cooperate with a national institution, a local government or a person commissioned by either of them,
who is conducting affairs required by law, and our asking for the requester’s consent may disturb the conduct of suchaffairs, or
5 We consign handling of personal information to the extent it is necessary in achieving the purpose of collection anduse.
Section 4. (Disclosure)
We duly follow our internal procedure regarding handling of personal information provided by you, to respond to your request
to notify the purpose of use, to disclose, to correct, add or delete, to suspend use, to destroy and to stop providing to a third
party.
Section 5 (Discretion of Provision of Your Personal Information)
Please note that although provision of your personal information is voluntary, we may not be able to respond to your request
if information necessary for our operation is not provided.
＜Personal Information Protection Manager＞

Executive Officer, Risk and Compliance＜For questions, please contact:＞
Credit Information Center Corp.
Domestic Call: 0570‐666‐414 (only in Japanese)
Mon-Fri 10：00～16：00 (Closed on Saturdays, Sundays, national holidays and new year holidays)

E1

2022.10

How to Fill Out a Credit Information Disclosure Request Form (sample)
Write your katakana-name accurately as you have registered with your credit card company or other institution.
(It also has to be fully identical to the name on at least one of your identiﬁcation documents.)
If there are not enough square blocks, use the blank area as well.
If you have more than one katakana names, ﬁll in the maiden name/byname ﬁeld below.
株式会社シー・アイ・ofシー（CIC）(A handling charge
1,500
yen宛per name applies.)
私は、CICの定める手続き方法に従い、別紙記載の「個人情報の取扱いに関する事項」に同意のうえ、私の信用情報の開示を申込みます。

信用情報開示申込書（ご本人様用）※Use a ball point pen and write clearly in your own handwriting as it will be OCR-ed.

カイジマイケル

タロウ

（姓）

（名）

※Any letter with a sonant/p-sound mark should ﬁt in one square block.

Kaiji Michael

現 氏 名
※必須

Taro

必須
※
生年月日

カナ氏名
※必須

大正

昭和

平成

0 9

2 7

Use Japanese calendar
and check □ for the era name.
年
月
日

5 7

the prefecture name in your address. (Either in Japanese or with alphabets).
〒 1 6 0 − 8 3 7 5 ※Include※Your current address must be proved by an identiﬁcation document.

東京

現 住 所
※必須

1 0 3

都
府

道
県

The disclosure report will be sent to the address of the “katakana-name” you provide.

新宿区西新宿 1-23-7○△マンション ○号
4 0 6− ○○○○ − ××××

− ×××× − △△△△

2 0 2 2 2 − × × × × Provide− △△5− and mobile phones,−△ phone△ numbers
all theincluding ﬁxed

電話番号
※必須

3 0 9 0which you may have used since the time of signing the contracts until now.

− △△△△ − ○○○○

−

6

−

※電話番号はクレジット契約等でご使用の番号（携帯・自宅）を、お調べになりたい順番にご記入ください。

1 2 3 4 − 5 6 7 8− 9 0 0 0 日中の 0 9 0

運
転
免 許 証
番
号

連 絡 先

※Provide your driverʼs license number
without fail if you have any.

− 1 2 3 4 − ○○○○

※Daytime phone number (of the requester only)

If you have more than one katakana names (including diﬀerent spellings), use this ﬁeld.
※1 旧姓等開示ご希望の場合のみ、ご記入ください。 ※2 濁点・半濁点のある文字も1マスで、ご記入ください。 【旧姓等での開示手続き】
希望する□にをご記入ください。

タロウマイケル

カイジ

（姓）

（名）

氏名
カナ氏名

Taro Michael

カイジ

タロウ
（名）

Kaiji

【お手続きにあたって】

現氏名＋旧姓等の開示を希望（追加料金）

旧姓等のみ開示を希望

Kaiji

（姓）

氏名

旧姓等
開 示
希望欄
②

カナ氏名

旧姓等
開 示
希望欄
①

※上記の内容にかかわらず、「旧姓等開示希望欄①②」にご記入がない場合は、現氏名のみの開示となります。
※確認書類・開示利用券等に不備がある場合は、受付不可・または現氏名のみの開示となります。
※お名前ごとに1,500円分の開示利用券等が必要です。
※旧姓等を確認できる書類を添付してください。
※旧姓等が3つ以上ある場合は、余白にカナ氏名と漢字
氏名を必ずご記入ください。

Taro

1.現住所は、建物名・部屋番号までご記入ください。ただし、Maiden Name/Byname ﬁeld: In case you would like
宛名のinformation
建 物 名につ い
ては 、省
させ て
い ただく場
related
to略yourmaidenname合 がございますのでご了承ください。
or other names to be disclosed, ﬁll this ﬁeld
(kanji and katakana-nameis required),
2.不備があった場合には、ご記入の電話番号または日中のand check □ for desired option.
連絡先へご連絡することがあります。
(We will not be able to search information if you do
3.住所による検索は行っておりません。
not provide any katakana-name.)
４.カナ氏名・生年月日・電話番号または運転免許証番号が一致した情報が報告されます。
5.本申込書および本人確認書類は、受付後、2ヵ月以内に当社が責任をもって廃棄いたします。
返却は、いたしかねますのでご了承ください。
6.通称名での開示をご希望の場合、「 旧姓等開示希望欄」にご記入ください。

③
カイジ

タロー

Kaiji Taro

Write in the margin in case
you have more than three
Maiden Names/Bynames.

郵送オプション手続きについて【速達・本人限定受取郵便をご希望の方】（有料）◆希望種別の□にのうえ開示手数料と合算した利用券等を同封してください。

速達
250円

本人限定受取郵便300円

速達＋本人限定550円※開示利用券等の添付や郵送オプションの指定に不備・不足がある場合、本人限定受取郵便での送付を優先して発送いたします。

Note: Failure to complete required ﬁelds (※) may result in no acceptance of your request.
Please make sure you provide all required information.

F5

株式会社シー・アイ・シー（CIC）
宛

信用情報開示申込書（ご本人様用）私は、CICの定める手続き方法に従い、別紙記載の「個人情報の取扱いに関する事項」に同意のうえ、私の信用情報の開示を申込みます。

※機械で読み込みいたしますので、ボールペンを使用し、自筆にてはっきりとご記入ください。

必須
※
生年月日

カナ氏名
※必須

※濁点・半濁点のある文字も1マスで、ご記入ください。
（姓）

現 氏 名
※必須

（名）

大正

昭和
年

〒

月

日

※住所は都道府県からご記入ください。
※報告書は現住所に送付します。現住所は本人確認書類で確認できることが必要です。

−
都
府

現 住 所
※必須

電話番号
※必須

平成

道
県

1

−

−

4

−

−

2

−

−

5

−

−

3

−

−

6

−

−

※電話番号はクレジット契約等でご使用の番号（携帯・自宅）を、お調べになりたい順番にご記入ください。

運
転
免 許 証
番
号

−

−

日 中 の
連 絡 先

※運転免許証番号が分かる場合は、必ずご記入ください。
カナ氏名

旧姓等
開 示
希望欄
①

−

※ご連絡先は、開示対象のご本人に限ります。

※1 旧姓等開示ご希望の場合のみ、ご記入ください。 ※2 濁点・半濁点のある文字も1マスで、ご記入ください。 【旧姓等での開示手続き】
希望する□にをご記入ください。

現氏名＋旧姓等の開示を希望（追加料金）

（名）

氏名

（姓）

旧姓等のみ開示を希望※上記の内容にかかわらず、「旧姓等開示希望欄①②」にご記入がない場合は、現氏名のみの開示となります。
※確認書類・開示利用券等に不備がある場合は、受付不可・または現氏名のみの開示となります。
※お名前ごとに1,500円分の開示利用券等が必要です。
※旧姓等を確認できる書類を添付してください。
※旧姓等が3つ以上ある場合は、余白にカナ氏名と漢字
氏名を必ずご記入ください。

カナ氏名

旧姓等
開 示
希望欄
②

−

（名）

氏名

（姓）

【お手続きにあたって】

1.現住所は、建物名・部屋番号までご記入ください。ただし、宛名の 建 物 名につ い ては 、省 略 させ て い ただく場 合 がございますのでご了承ください。
2.不備があった場合には、ご記入の電話番号または日中の連絡先へご連絡することがあります。
3.住所による検索は行っておりません。
４.カナ氏名・生年月日・電話番号または運転免許証番号が一致した情報が報告されます。
5.本申込書および本人確認書類は、受付後、2ヵ月以内に当社が責任をもって廃棄いたします。
返却は、いたしかねますのでご了承ください。
6.通称名での開示をご希望の場合、「 旧姓等開示希望欄」にご記入ください。

郵送オプション手続きについて【速達・本人限定受取郵便をご希望の方】（有料）◆希望種別の□にのうえ開示手数料と合算した利用券等を同封してください。

速達

本人限定受取郵便250円

速達＋本人限定

300円

550円

※開示利用券等の添付や郵送オプションの指定に不備・不足がある場合、本人限定受取郵便での送付を優先して発送いたします。

〈CIC使用欄〉※こちらの欄には記入しないでください。
添付書類

有効期限

附

本

人

免

保

受領金額

コ

件

送付手段
返 却 物
連

通
住
ケ

円
切手
カ

コ

0 1 1 0

住

0

個

住基

件
速達

円

TEL 確

他
年

チ

件

本人限定

小為替
旧

パ
ヒ

漢

印

手

在

他

合計

円

速達＋本人限定
円

ア

戸

他

原

キ
他申

確

封
開

他
封

確

認

2
F35