/〈郵便番号〉〈住所〉〈借受人姓〉〈借受人名〉

SPCSW No.
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〈貸付コード〉〈バーコード〉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

Notice of Repayment Balance and Application for FY2024 Repayment Forgivenessfor ≪ 資金名称 ≫【Notice of Repayment Balance of Special Loans for Emergency Small Amount Funds】

We hereby inform you of the current repayment balance (as of the creation reference date) of ≪資金名称≫, whichis currently in its repayment period, as shown below. Please note that the repayment balance may differ if any
repayments have been made after the creation reference date.
In addition, those who were subject to inhabitants tax in FY2023 can apply for repayment forgiveness in FY2024 if
they meet the requirements. For details, please refer to the enclosed information booklet and submit the application
form on the right.
Details[Creation reference date: ≪令和 yy 年 mm 月 dd 日≫]Fund Name
Borrower's Name

≪資金種類≫≪借受人姓≫≪借受人名≫

Loan Code≪貸付コード≫Loan amount≪貸付額≫

Repayment period≪yy 年 mm ヵ月≫

Repayment start date

≪償還開始日≫

Repayment deadline≪償還期限日≫Amount already repaid≪償還済額≫ yen

Outstanding amount to be repaid≪償還残額≫ yen

Amount in arrears out of theoutstanding amount to be repaid≪滞納額≫ yen

◆ Documents sent this time (enclosed items)① Notice of Repayment Balance and Application for FY2024 Repayment Forgiveness, and Application form for
repayment forgiveness (this document)② "Special loans for which repayment forgiveness will be applied in FY 2024" information booklet *Please see
P.4 for instructions on how to fill out the application form.

③ Return envelope[For Applications and 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

(Form 1-1)

Application Form for Repayment Forgiveness for Special Loans for Comprehensive Support FundFor ≪資金名称≫* Please fill in all fields in the bold frame.
Type of fundBorrower'sName
Loan amountReason forexemption
application
Householdstatus* Pleaseindicate yourhousehold
status byadding a ☑ toany one of
the following

Requireddocuments* Prepare thedocuments
and add a ☑ tothe box≪資金名称≫≪借受人姓≫≪借受人名≫≪差し込み≫

yen

Amount of exemption
applied for

Maximum amount of repayment forgivenessfor the type of fund in question

I am exempt from both per-capita and per-income inhabitants tax.
I (the borrower) am currently the head of thehousehold
Someone other than the borrower is currently
the head of the household, and the current headof the household was in a separate householdfrom the borrower at the time of loan applicationA person other than the borrower is currently
the head of the household, but I (the borrower)
cannot obtain an income certificate for the headof the household as I have evacuated due todomestic violence, etc.
All three documents below are required

If none of the statuses on the left applies to theborrower

All three documents below are required

Exemption application form (this document)
An original of the certificate of residence
showing all members of the current household(Bearing the name of the head of the household
and relationship to the head of the household)An original of the borrower’s FY 2024
certificate of inhabitants tax exemption * Which

Exemption application form (this document)
An original of the certificate of residence
showing all members of the current household(Bearing the name of the head of thehousehold and relationship to the head of thehousehold)Originals of the borrower’s and the head of
the household’s 2024 certificate of
inhabitants tax exemption * Which states that thestates that the borrower is exempt from both the "percapita" and "per-income" portions of inhabitants tax

borrower and the head of the household are exempt fromboth the "per-capita" and "per-income" portions ofinhabitants tax

To 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 the purpose 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 of social welfare, municipal councils of social welfare, local governments, publicemployment security offices, self-reliance support consultation agencies, household financial improvement support
organizations, and other related organizations to receive my personal information to the extent necessary for thisprogram.
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 crimegroup 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 constituentorganizations) to engage in violent unlawful acts, etc. collectively or habitually.")⑤ I agree that if repayment forgiveness is rejected as a result of the screening, the reason for the rejection will not bedisclosed.
⑥ I have not changed the head of the household for the purpose of receiving repayment forgiveness. I also agree thatthe repayment forgiveness will be revoked if any of the information in this application is found to be false or if any of
the requirements for repayment forgiveness are found to be not applicable after the decision for repayment
forgiveness has been made.
//* Write the date you filled out this form * Please sign your name exactly as it appears above.
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 Code

SX≪差し込み≫

Receipt No.

Saitama Prefectural CSW
Reception

Barcode≪差し込み≫/

Fund Code≪差し込み≫/