11-1

SPCSW No. 491
May 30, 2023

330-8529

2F Sainokuni Sukoyaka Plaza
4-2-65 Harigaya, Urawa-ku, Saitama-shi, Saitama
Taro Saitama

Saitama Prefectural Council of Social Welfare
Repayment and Exemption of COVID-19 Special Loan Section

Special loans such as emergency small amount funds due to the impact of the COVID-19 pandemic

Information Regarding Repayment Forgiveness and Repayment

Notification of Exemption and Repayment
This is to inform you of the upcoming repayment forgiveness and repayment of emergency small amount funds andother special loans for COVID-19 that are provided by the Council.
Please review the following documents regarding repayment forgiveness and repayment carefully.

1. Documents sent this time (enclosed items)*There will be a form for each fund borrowed, so if you have multiple types of loans, you will receive multiple envelopes.

(1)

(2)

(3)

Application form for repayment forgivenessSpecial loans eligible for repayment
forgiveness (booklet)

Return envelope* There is an example of how to fill in the form on the reverse side

Please read the booklet (2) carefully and confirm the procedures for repayment
forgiveness and repayment.
2. For Inquiries
Saitama Prefectural Council of Social Welfare,
Repayment and Exemption of COVID-19 Special Loan Section[Telephone Number] ☎ 050‐2018‐1839[Reception Time] Weekdays 9:00 am to 5:00 pm

https://www.fukushi-saitama.or.jp/site/problem_33.html* Available in several languages for foreigners[Requests]•••

We do not accept documents directly. Please refrain from bringing your documents to thisoffice.
It may be difficult to get through by phone immediately after receiving this notice. Please beaware of this.
Documents cannot be returned once submitted. Please be aware of this.

(Form 1-1)
Application Form for Repayment Forgiveness for Special Loans for Emergency Small Amount Funds, etc.
For Emergency Small Loan Funds<Council Use Only>* Please fill in all fields in the bold frame.
Type of fund

Emergency small amount funds

Borrower's Name

Taro Saitama

Loan amountReason for exemption
application

Amount of exemption
applied for

100,000 yen

Maximum amount of repayment forgiveness for the type offund in question

I am exempt from both per-capita and per-income inhabitants tax.
 I (the borrower) am currently the head of thehousehold

Household status* Please indicate yourhousehold status byadding a  to any oneof the following

 Someone other than the borrower is currently
the head of the household, and the current headof the household was in a separate from theborrower at the time of loan application

 If none of the statuses on the left applies to theborrower I (the borrower) cannot obtain an income
certificate for the head of household as I haveevacuated due to domestic violence, etc. (aperson other than the borrower is currently thehead of the household).

(1) (All three documents below are required)

Required documents(2) (All three documents below are required)(1)-1: Exemption application form (this document)(2)-1: Exemption application form (this document)(1)-2: A copy of the certificate of residence showing all
members of the current household(Bearing the name of the head of the household andrelationship to the head of the household)(2)-2: A copy of the certificate of residence showing all
members of the current household(Bearing the name of the head of the household andrelationship to the head of the household)(1)-3: Borrower's taxation certificate for FY 2023
(Certificate showing that the borrower is exempt frominhabitants tax)(2)-3: Taxation certificates of the borrower and thehead of the household for FY 2023
(Certificate showing that the borrower is exempt frominhabitants tax)

* Those who are exempt from both per-capita and perincome inhabitants tax are eligible for forgiveness* Those who are exempt from both per-capita and perincome inhabitants tax are eligible for forgivenessTo the Chair of the Saitama Prefectural Council of Social Welfare

I agree to the following six items and hereby apply for an exemption.
(1)If repayment forgiveness is approved, I agree to my personal information being provided to a self-reliance support consultation agency for thepurpose of utilizing it in the performance of the organization's duties.
(2)I agree to my personal information being provided to third parties to the extent necessary for this program.
(3)I agree that the Saitama Prefectural Council of Social Welfare may query the National Council of Social Welfare, other prefectural councils ofsocial welfare, municipal councils of social welfare, local governments, public employment security offices, self-reliance support consultation
agencies, household financial improvement support organizations, and other related organizations to receive my personal information to theextent necessary for this program.
(4)Neither I nor any members of my household are members of an organized crime group. I agree that the Saitama Prefectural Council of Social
Welfare may request, as necessary, information from government and other public offices pertaining to my, or my household members',
membership in an organized crime group. (Organized crime group is defined in Article 2, Item 2 of the "Act on Prevention of Unjust Acts by
Organized Crime Group Members," as "An organization that is likely to encourage its members (including members of the organization's
constituent organizations) to engage in violent unlawful acts, etc. collectively or habitually.")(5)I agree that if repayment forgiveness is reject as a result of the screening, the reason for the rejection will not be disclosed.
(6)I have not changed the head of household for the purpose of receiving repayment forgiveness. I also agree that the repayment forgivenesswill be revoked if any of the information in this application is found to be false or if any of the requirements for repayment forgiveness arefound to be not applicable after the decision for repayment forgiveness has been made.

20//* Please sign your name as printed above* Write the date you filled out this form

Borrower’s Name (Signature)
Borrower’s Name (Signature)−Telephone Number−* Provide a telephone number where you can be reached during the day.

* The information below is not to be filled by the applicant*Fund CodeLoan CodeKA1234567

Receipt No.

Saitama Prefectural CSW Reception//

Entry example[Please write clearly and strongly with a ballpoint pen without going outside the frame]

Do not fill in
Refer to P.2 of the booklet

Refer to P.3 of the booklet

Refer to theapplicable pagein the booklet
and check thebox(es)Please confirm all
items (1) through(6)･ Date filled out･ Signature･ Telephone
numberPlease do notforget to fill thesein

Do not fill in Please check the box properly (clearly) with a✓.
Good example

Bad examplesetc.