Claim for Survivors Pension

You can find the deceased person’s Japanese
Basic Pension Number or Number on Pension
Handbook on his/her Notice of Basic Pension
Number or on his/her Pension Handbook.

- ① and ②: Please capitalize in Roman letters.
(Please do the same to fill in the other “in Romanletters” blanks on this form.)- Also, you may fill them in “in Katakana letters”, if
they are available. (Please do the same to fill inthe other “in Katakana letters” blanks on thisform.)

You can find your Japanese Basic Pension
Number or Number on Pension Handbook on
your Notice of Basic Pension Number or on
your Pension Handbook.

Please enter the four-digit year and two digit
month, such as “1955 12 15” for December 15,1955. (Please do the same to fill in the other“Date” blanks on this form.)

If the deceased person claimant has eligible
child(ren), please fill in this section.
If the claimant is the child and has sister(s) and/orbrother(s), please enter them here.
An eligible child is a child who, on March 31, isage 18 or younger, or is aged under 20 if he/she is disabled.
死亡者

Please capitalize in Roman letters the bankname and branch name.

Please indicate whether the claimant is receiving
or in the process of filing a claim for anotherJapanese public pension for old age, disability ordeath (Refer to the list of applicable public pension
systems). If so, please enter the name of thepublic pension system, type of pension, date ofentitlement, Pension Code or Number on Pension
Certificate.
If the claimant is receiving one of the Mutual Aid
pensions, please enter the name of the Mutual Aid
Association under “Name of system”.

Applicable public pension systems
A. National Pension Law
B. Employees’ Pension Insurance Law
C. Seamen’s Insurance Law (Only before April1986)
D. Law concerning Mutual Aid Association for
National Public Officials(Including the Laws concerning theImplementation of Long Term Benefits enacted
before April 1986)
E. Law concerning Mutual Aid Association for
Local Public Officials(Including the Laws concerning theImplementation of Long Term Benefits enacted
before April 1986)
F. Law concerning Mutual Aid for Private SchoolPersonnel
G. Law concerning Mutual Aid Association for
Agricultural, Forestry and Fishery Institutions’Employees
H. Law concerning Public Servants’ Pension
I. Local Government Ordinance concerning
Retirement Pension for Local Public Officials
J. Law concerning Mutual Aid Association for
Miners at Government-owned YAWATA Worksof Nippon Steel Co.
K. Supplementary Provision Article No. 13 of theDistrict Court Special Officials Law
L. Law concerning Special Measures for Former
MAAs’ Beneficiaries
M. Law for Relief of War Victims and Survivors

If you are not sure of the specific dates, enter as
much information as you know, such as month orseason, e.g. summer of year xxxx.

- Please enter the deceased person’s history ofcoverage under Japanese public pension systems
in chronological order from the oldest/firstcoverage to the most recent one.
- If the deceased person’s address changed
during the time he/she was covered by theNational Pension, please specify the old address
and the period of residence.

- Please enter the address. You must at least
provide the name of the county, city or ward, if
you do not know the details.
- Some employees who are actually working in
Osaka branch office of a company may havebeen enrolled to the Employees’ Pension
Insurance (EPI) at the Social Insurance Office inTokyo where the workplace’s headquarters islocated. If yours is such case, enter the addressof the workplace where you were enrolled in theEPI.
- Please do the same for workplaces of a Mutual
Aid Association.

- If there was any change in name or address of aworkplace or if he/she was transferred between
branch offices while he/she was covered under
the Employees’ Pension Insurance and such,please enter each workplace’s name, address,
period of coverage and name of pension system
respectively.

- Please enter the official name of the workplace
which was reported to the Social Insurance
Office or the Regional Social Insurance Bureau
during the time he/she were covered.
- As for workplaces, enter the specific name of
the branch offices or factories as well, such as
Tokyo branch office of corporation A.
- Please do the same for workplaces of a MutualAid Association. If available, enter theJapanese name.

From ① through ⑤: Please refer to the document providing the date of death such as the deceased
person’s death certificate.

Please complete Section 8 if there are persons whose priority order is the same order.

cf. priority order(1) The deceased person’s wife
(2) The deceased person’s child(ren) who, on March 31, is(are) age 18 oryounger* (under age 20 or younger if with a certain grade of disability specified by law)(3) The deceased person’s husband aged 55 or older(4) The deceased person’s father or mother aged 55 or older(5) The deceased person’s grandchild(ren) who, on March 31, is(are) age 18 oryounger* (under age 20 or younger if with a certain grade of disability specified by law)
(6) The deceased person’s grandfather or grandmother aged 55 or older（参考） 順位
１. 妻
２. 18歳到達日以後の最初の3月31日までの間にある子（法で定められた一定の等級の障害のある20歳未満の子）
３. 55歳以上の夫
４. 55歳以上の父母
５. 18歳到達日の最初の3月31日までの間にある孫（法で定められた一定の等級の障害のある20歳未満の孫）６. 55歳以上の祖父母

In signing, you attest to the truth of the information given in
the application.
You also authorize the Irish competent institution to provide
to the Japanese competent institutions information which may
affect your entitlement to the Japanese benefits for which youare applying.
Furthermore, in case the deceased individual was covered by
two or more Japanese pension schemes, you authorize theJapanese competent authorities exchange information on
periods of coverage under the Japanese pension schemes forthe purpose of eligibility assessment concerning this claim forbenefits.
If not, you must obtain certificate(s) of his/her coverage
periods from each of the Japanese competent institution
which keeps his/her coverage records, and then attach themwith this claim.
下線部に署名をしてください。
署名に際して、あなたは申請書で提供した情報が真実であることを証明します。
あなたはアイルランドの実施機関に対し、あなたが申請している日本年金の給付を受ける資格に影響を与えうる情報を日本の実施機関に提供する権限を与えます。
そして、死亡した方が複数の日本の年金制度に加入していた場合、あなたが申請している日本年金の審査のために、日本の実施機関に対し、日本の実施機関が年金加入期間に関する情報交換を行う権限を与えます。
署名がない場合、死亡した方が加入していた各日本の実施機関から、年金加入期間の証明を入手して、請求書に添付する必要があります。