Claim for Old Age / Disability Pension

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

- ①, ② and ⑤: 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.)

If you have an eligible spouse, please fill in thissection.
An eligible spouse includes a de facto spouse(common-law spouse) to whom you are not legallymarried.

Your spouse's Japanese Basic Pension Number or
Number on Pension Handbook will be on his/her
Notice of Basic Pension Number or on his/herPension Handbook.

For “Type of benefits claimed”, please check theappropriate box to indicate the benefit you areclaiming.

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 you have an eligible child(ren), please fill in thissection.
An eligible child is a child who on March 31, is age
18 or younger, or is aged under 20 if he/she isdisabled.

Please capitalize in Roman letters the bank nameand branch name.

- Section 5.1: Please indicate whether you arereceiving or in the process of filing a claim foranother Japanese public pension for old age,disability or death (Refer to the list of applicablepublic pension systems). If so, please enter thename of the public pension system, type ofpension, date of entitlement, Pension Code or
Number on Pension Certificate. If you arereceiving more than one public pension, pleaseattach the additional information.
If you are receiving one of the Mutual Aidpensions, please enter the name of the Mutual
Aid Association under “Name of system”.
- Section 5.2: Please indicate information about
your spouse’s benefit, if applicable, in the samemanner indicated above.

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
theLaws
concerning
theImplementation of Long Term Benefits
enacted before April 1986)
E. Law concerning Mutual Aid Association for
Local Public Officials(IncludingtheLaws
concerning
theImplementation of Long Term Benefits
enacted before April 1986)
F. Law concerning Mutual Aid for Private
School Personnel
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
Works of Nippon Steel Co.
K. Supplementary Provision Article No. 13 ofthe District 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 official name of the workplace
which was reported to the Social Insurance
Office or the Regional Social Insurance Bureau
during the time you were covered.
- As for workplaces, enter the specific name of thebranch offices or factory as well, such as Tokyo
branch office of corporation A.
- Please do the same for workplaces of a Mutual
Aid Association. If available, enter the Japanesename.

- Please enter your history of coverage underJapanese public pension systems in chronologicalorder from the oldest/first coverage to the mostrecent one.
- If your address changed during the time you werecovered by the National Pension, please specify
the old address and the period of residence.
- If there was any change in name or address of aworkplace or if you were transferred betweenbranch offices while you were covered under theEmployees’ Pension Insurance and such, please
enter each workplace’s name, address, period ofcoverage and name of pension system
respectively.

- 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 theOsaka branch office of a company may havebeen enrolled in the Employees’ Pension
Insurance (EPI) at the Social Insurance Office inTokyo where the workplace’s headquarters islocated. If this applies to you, enter the addressof the workplace where you were enrolled in theEPI.
- Please do the same for workplaces of a Mutual
Aid Association.

In signing, you attest to the truth of the information given inthe application.
You also authorize the U.S. competent institution to provide
to the Japanese competent institutions information which may
affect your entitlement to the Japanese benefits for which you
are applying.
Furthermore, in case you were/have been covered by two or
more Japanese pension schemes, you authorize the Japanesecompetent authorities exchange information on periods ofcoverage under the Japanese pension schemes for the purposeof eligibility assessment concerning this claim for benefits.
If not, you must obtain certificate(s) of your coverage periods
from each of the Japanese competent institution which keeps
your coverage records, and then attach them with 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。
あなたはアメリカの実施機関に対し、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、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、あなた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。

If you are claiming adisability benefit, please
complete this section.

Section 7.1: Please check one of the two types ofclaim below:① Claim for benefits based on the onset of disability
while contributing the pension system under theAgreement:
If you have a certain level of disability on the day
when the one year and six months has elapsed
since your first medical examination of the sickness
or injury, you can claim this benefit. You can also
claim this benefit if you recover from your sickness
or injury at an earlier date than the one year and six
months. If this applies, the effective date will be theday of recovery. Please note you need to havecertain periods of coverage to be eligible.
② Claim for benefits based on advanced degree ofdisability:
If the conditions of ① above do not apply to you, you
can still claim this benefit if your disability advances
to a certain level at a later date. Please note you
must apply before you attain age 65. You are entitledto the benefit the month following the month of yourclaim.