[1]Non-taxable for the fiscal year 2024

R6.5(Form 1-1) Application Form for Repayment Exemption for Special Loans for Emergency Retail Fund, Etc.
<Cutting line>< Column to be used by the Council >*Please fill in everything following the example on the reverse side.

Comprehensive Support Fund (Relending)Fund Name
Name ofBorrower

Reason forApplication forExemption

Gifu Prefectural Council of Social Welfare, a social welfare corporation
Livelihood Support Department, Fund Loan Section

Status ofHousehold

Notification of Exemption and Repayment*Please check ☑
for any one of thefollowings

We hereby inform you as follows, in connection with the commencement of redemption (repayment) ofthe Special Loans for Emergency Retail Fund Due to Impact of New Coronavirus Infection having been
loaned by our council.
This is an important notice, so please be sure to check it.
Particulars:
RequiredDocuments

An example of how to fill out theform is provided on the reverseside.

[2]

Procedure Confirmation Flowchart / Notification of Repayment Exemption*Please be sure to check thefollowing[3]

List of mailing addresses (CSW of each municipality) and other informationOther information is written on thereverse side.

[4]

Notification of change of name/address

An example of how to fill out theform is provided on the reverseside.

- Documents are not accepted in person. Please do not bring the documents with you to complete theprocedure.
- For further information on this matter, please contact the above telephone number.
Immediately after this notice is delivered, for example, it may be difficult to get through to the phone.
Thank you for your understanding.
- We cannot return documents that have been submitted once. Thank you for your understanding.
- It may take about one month from the time of application to receive the result of approval or disapproval of
the exemption.

[2] (All of the following three documents

required)[1]-1: Application form for exemption (this document)[2]-2: A certificate of residence containing all members of thecurrent household (one containing the name and relationshipof the head of household)[3]-3: Tax certificate of the borrower for fiscal year 2024(showing that he/she is exempt from residential tax)

are required)[2]-1: Application form for exemption (thisdocument)[2]-2: A certificate of residence containing all
members of the current household (one containing
the name and relationship of the head ofhousehold)[2]-3: Tax certificates of the borrower and thehead of household for fiscal year 2024 (showingthat they are exempt from residential tax)

To: Chairman of Gifu Prefectural Council of Social Welfare
For application, I agree to the following six items and apply for exemption.
[1] I agree to provide my personal information to the independence counseling support organization for the purpose of utilizing suchinformation for the performance of the work of said organization, in the event that the decision is made for the exemption of therepayment under this special exemption program.
[2] I agree to provide the filled out personal information to a third party to the extent necessary for this program.
[3] I agree that your council will make inquiries to relevant organizations, such as Japan National Council of Social Welfare, otherprefectural councils of social welfare, municipal councils of social welfare, local governments, public employment security offices,
independence counseling support organizations and organizations for support of household economy improvement, and will
receive my personal information to the extent necessary for this program.
[4] Neither I nor any member of my household is a member of an organized crime group. I agree that your council may, as
necessary, request from public agencies, etc. the provision of organized crime group membership information pertaining to me ormembers of my household. [An “organized crime group” means “an organization that is likely to encourage its members(including members of organizations constituting such organization) to collectively or habitually commit violent and illegal acts,etc.” as stipulated in Article 2, Item (ii) of the Act on Prevention of Unjust Acts by Organized Crime Group Members.][5] I agree that even if the examinations result in the disapproval of the repayment exemption, the reasons will not be disclosed.
[6] I have not changed the head of household for the purpose of repayment exemption. In addition, I agree that if the information
stated in this application form is found to be false or if it is found that the requirements for repayment exemption are not met after
the decision of the repayment exemption, the repayment exemption will be rescinded.
_______________, ______ (Month Day Year) *Please insert the date you completed this document<Cutting line>[Note]

Currently, a person other than the borrower is thehead of household, but because of the evacuation
due to domestic violence, etc., the borrower isunable to obtain an income certificate for the headof household.

The case does not fall into any of thecategories listed on the left

*Those who are exempt from both per capita and per income
residential taxes are eligible for the exemption.

2. Contact Information

Incorporated.

Currently, a person other than the borrower is thehead of household, and the current head ofhousehold was in a separate household from theborrower at the time of the loan application.

*Those who are exempt from both per capita and per income residential
taxes are eligible for the exemption.

[2] Please follow the flowchart to identify the procedures that apply to you, and thenplease follow the procedures for exemption from repayment and for repayment.
Fund Loan Section, Livelihood Support Department, Gifu Prefectural
QR code forCouncil of Social Welfare
information on our[Telephone Number/Contact Number] 058‐201‐2100
websiteQR code is a registered[Hours for Acceptance/Reception Time] Weekdays 9:00 a.m. to 5:00 p.m. trademark of Denso Wave

Both per capita and per income residential taxes are exempt from taxation.

[1] (All of the following three documents are

1. Documents (enclosures herein) sent to you this time[1]

Maximum amount of repayment exemption of the relevant
type of funds

I am (Borrower is) currently the head of household.

Special Loans for Emergency Retail Fund Due to Impact of New Coronavirus Infectious Disease

Notice Concerning Special Loans for Emergency Retail Fund (this notice)/ Application Form for Repayment Exemption (for Non-TaxableHouseholds) *Right side of this notice
Certificate of tax exemption (flyer)

AmountApplied for
Exemption

yen

Loan Amount

Borrower's Name (Signature)
Phone Number/TEL*

Loan Code--Please provide a phone number where you can be reached during the day.

Accepted by Prefectural Council ofSocial Welfare

Accepted by Municipal Council ofSocial Welfare[Month] [Day], [Year][Month] [Day], [Year]<Cutting line>

Example of Description[Please write with a ballpoint pen]
(Form 1-1) Application Form for Repayment Exemption for Special Loans for Emergency Retail Fund, Etc.
< Column to be used by the Council >*Please fill in everything following the example on the reverse side.
Fund Name

No entry required

Name ofBorrower

Reason forApplication for
Exemption

AmountApplied for
Exemption

yen

Loan AmountMaximum amount of repayment exemption of the relevant
type of funds

Both per capita and per income residential taxes are exempt from taxation.
I am (Borrower is) currently the head of household.

Status ofHousehold*Please check ☑
for any one of thefollowings

Currently, a person other than the borrower is thehead of household, and the current head ofhousehold was in a separate household from theborrower at the time of the loan application.
Currently, a person other than the borrower is thehead of household, but because of the evacuation
due to domestic violence, etc., the borrower isunable to obtain an income certificate for the headof household.

[1] (All of the following three documents are

RequiredDocuments

The case does not fall into any of thecategories listed on the left[2] (All of the following three documentsrequired)[1]-1: Application form for exemption (this document)[2]-2: A certificate of residence containing all members of thecurrent household (one containing the name and relationshipof the head of household)[3]-3: Tax certificate of the borrower for fiscal year 2024(showing that he/she is exempt from residential tax)
*Those who are exempt from both per capita and per income residential
taxes are eligible for the exemption.

are required)[2]-1: Application form for exemption (thisdocument)[2]-2: A certificate of residence containing all
members of the current household (one containing
the name and relationship of the head ofhousehold)[2]-3: Tax certificates of the borrower and thehead of household for fiscal year 2024 (showingthat they are exempt from residential tax)
*Those who are exempt from both per capita and per income
residential taxes are eligible for the exemption.

To: Chairman of Gifu Prefectural Council of Social Welfare
For application, I agree to the following six items and apply for exemption.
[1] I agree to provide my personal information to the independence counseling support organization for the purpose of utilizing suchinformation for the performance of the work of said organization, in the event that the decision is made for the exemption of therepayment under this special exemption program.
[2] I agree to provide the filled out personal information to a third party to the extent necessary for this program.
[3] I agree that your council will make inquiries to relevant organizations, such as Japan National Council of Social Welfare, otherprefectural councils of social welfare, municipal councils of social welfare, local governments, public employment security offices,independence counseling support organizations and organizations for support of household economy improvement, and will
receive my personal information to the extent necessary for this program.
[4] Neither I nor any member of my household is a member of an organized crime group. I agree that your council may, asnecessary, request from public agencies, etc. the provision of organized crime group membership information pertaining to me ormembers of my household. [An “organized crime group” means “an organization that is likely to encourage its members(including members of organizations constituting such organization) to collectively or habitually commit violent and illegal acts,etc.” as stipulated in Article 2, Item (ii) of the Act on Prevention of Unjust Acts by Organized Crime Group Members.][5] I agree that even if the examinations result in the disapproval of the repayment exemption, the reasons will not be disclosed.
[6] I have not changed the head of household for the purpose of repayment exemption. In addition, I agree that if the information
stated in this application form is found to be false or if it is found that the requirements for repayment exemption are not met after
the decision of the repayment exemption, the repayment exemption will be rescinded.
_______________, ______ (Month Day Year) *Please insert the date you completed this document

Borrower's Name (Signature)
Phone Number/TEL*--

Please provide a phone number where you can be reached during the day.

<Cutting line>

Accepted by Prefectural Council ofSocial Welfare

Accepted by Municipal Council ofSocial Welfare[Month] [Day], [Year][Month] [Day], [Year]No entry required
Loan Code

Please check ✓ exactly (clearly) in the box □.
OK:
ExampleNG:
Example[2] Please refer tothe flowchart on
the front page andcheck appropriatepartsand so on

Please check all ofItems [1] through[6]- Date of entry- Name in own
handwriting- Telephone
NumberDo not forget towrite it down