FY2024 Social Welfare Grant Program 海外助成申込書 2024 年度

International Grant Application Form

Selection ID

To: Sompo Welfare Foundation
As a recommender, I will apply for the social welfare international grant program.
* Please check (☑) the relevant check box (□) and indicate the details.

1. Recommender(Administration office use only)
Receipt ID
Receipt stamp

Decision ID

2024/MM/DD

推薦者

Affiliation 所属(Company name. etc.)
Name 氏名Contact 連絡先

TEL:

Email□ Applicable (Address:

Recommender’scomments
推薦者コメントFAX:) □ N/A*Indicate the relationship with the recommender and the recommended organization andreason for the recommendation.
*Please be sure to add the English-to-Japanese translation when written in English.
※英訳で記載した場合、こちらに必ず和訳も記載してください。

2. Summary of recommended organization 推薦する団体の概要
Please confirm the following two points with the organization before submitting the application.
☐ The organization agrees to disclose the name of organization, name of representative, address, project content, and grant amount if
they are selected for the grant.

☐ The organization is not related to any antisocial elements. 団体が反社会的勢力とは一切関わりがないこと。
Name of organization
団体名
Contact 連絡先

TEL:

Email□Applicable (Address:) □ N/AWebsite□Applicable (http://) □ N/A

Representative 代表者(First name, family name)FAX:

Name and his/her title:

Address of organization
団体住所
Contact of person in Name and his/her title:
charge担当者連絡先TEL:

FAX:*Please ask the following information to the recommended organization and fill out the fields to the best of your knowledge.
(Be sure to fill all the fields marked with a star [★] .Others than those are voluntary.) ★は必須項目
MM/YYYY★Date ofestablishment 設立年月
Have you previously□ Yes (FY: YYYY) □ No
received our grant?
Number of organization Board member: Number of board of directors:
Staff member: Number of full-time staff:
staff 団体職員の数
Number of volunteers
Membership 会員数(Including the number of Japanese:
Number of regular members:

Number of auditors:
Number of part-time staff:)

Number of supporting members:

★Income andexpenditure in the last
two years 収支状況
*Specify in the local
currency.
** Specify usedcurrency code.
★Total assets oforganization 総資産額
* Specify in the local
currency.
** Specify usedcurrency code.
★Mission oforganization
団体のミッション- Income and expenditure account statement in the previous year (FY2023)
Total income(Currency code:)

Total expenditure(Currency code:)- Income and expenditure budget sheet in the current fiscal year (FY2024)
Total income(Currency code:)

Total expenditure(Currency code:)(Currency code:)*Indicate briefly the official statement of the organization.

*Specify five major projects implemented in the previous fiscal year.
1)
2)
3)
4)
5)

Implemented activities
団体の活動実績※具体的に記入してください*Indicate the implemented activities in the past specifically including the characteristics and detailsof the activities of the organization.
*If the organization has any relation to Japan (e.g. funding or participation of management
staffs/volunteers), indicate specifically.

*Specify the name of organization (e.g. administrative body, university, embassy, JICA) you workwith for the projects, if any.

*Please be sure to add the English-to-Japanese translation when written in English.

※英訳：英語で記載した場合、こちらに和訳も記載してください。

3. Proposed project for grant (grant project) 本助成に申請する事業 (助成対象事 業 )Please ask the following information to the recommended organization and fill out the fields to the best of your knowledge.
(Be sure to fill all the fields marked with a star [★] .Others than those are voluntary.)*When this section is written in English, Please provide us with the Japanese translation in Section 7.

★Project name
事業の名称
Main project field
主な事業分野□ Children □ Elderly □ Disabled (physically, intellectually, mentally, developmentally)□ Poverty or Inequality □ Others ()★Goal and purpose ofproject, and project
policies
事業の目標目的、方針★Impact expected asa result of project
実施後の効果Prospects after nextyear
次年度以降の展望*Indicate the prospects of the continued efforts after the next year regarding the proposed project.

Please specify the following fields if the target of the project is disabled people. 障害者を対象とする場合に記載
Type and number of □ Number of physically disabled:□ Number of intellectually disabled:
people (number of □ Number of mentally disabled:□ Others (Specify:):people involved in theproject) 利用者数
Mean number of people involved per day:Total number of people involved in a year:

4. Application amount of grant, expected income/expenditure, and use of the grant
助 成 金 申 請 額と収支 見込・助成金使途
Specify in the local currency.
Application
amount
助成金額

現地通貨で記入(Currency code:*Exchange rate to JPY (1 local currency =(up to 1,000,000 JPY 上限１００万円 )Income of the project 本事業の収入
Amount 金額(Specify in the local currency)

1．Internal funds
自己資金)
JPY, Exchange date: MM/DD)

Expenditure of the project 同支出
1 ． Major expense items
that is to be covered by thegrant
主な助成金充当費目* Specify the breakdown
so that the basis forcalculation
canbeunderstood.

Amount 金額(Specify in the local currency )２．Amount applied tothis grant
本助成申請金額
３．Other income
その他収入*Specify other income, ifany. あれば記入

2.Total amount of expense
items that are not to becovered by the grant
助成金対象外の費目の合計
Total income（１＋２＋３）
合計収入金額Total expenditure（１＋２）
合計支出金額*Total income should be equal to total expenditure. 合計収入と合計支出金額は一致させてください。
*Please note that it is not acceptable to use the grant for expense items that are not intended to be covered by
the grant. 助成金の対象とならない費目への資金使途は認められません。
*Covered items (example): Personnel expenses, speaker fees, meeting expenses, purchase of equipment/furniture andfittings/appliance/supplies, travel expenses, communication expenses, printing cost, and repair and construction
expenses 対象費目（例）：人件費、講師謝金、会議費、機材・什器・備品、交通費・通信費、印刷費、工事改修費
Note: Personnel expenses shall be up to 30% of the grant amount. 人件費は助成額の３０％限度

5. Previously received grant

過去の助成歴If the organization received any grants in the last two years, specify the year, name of the granting organization, details of
the grant, and the grant amount. 過去 2 年間に受けた助成について 受給年・助成団体名・助成内容・金額
Specify the following fields if the organization is applying for grants of any other organizations regarding the same or related
project. 本事業と同じまたは関連する活動について、他の助成団体に申請している場合、記入
Name of granting organization:
Application theme (Project name):
Application amount:(Currency code:)

The result will be informed on: YYYY/MM

6. Attached documents (Documents we require from the recommended organization) 添付書類
Please collect the following documents, 1) to 7), from the recommended organization, and send them to us.
(Please send them within the application period.)
Check

Attached documents required
1) Brochure or the like which provides summary of the organization

団体のパンフレットなど

2) Income and expenditure account statement (previous fiscal year)

収支計算書(前年度)3) Income and expenditure budget statement (current fiscal year)

収支予算書（当年度）4) Balance sheet (previous fiscal year)

貸借対照表(前年度)5) Project report (previous fiscal year)

事業報告書(前年度)6) Project plan (current fiscal year)

事業計画書（当年度）7) Approximate estimation sheet (for goods purchasing or the like)

概算見積書（物品購入等の場合）(Please specify here if any other documents are enclosed)

その他、添付資料があれば記入

 書類の取り付けなどについて、ご質問があれば財団にご連絡ください。

7. Please fill out the following fields in Japanese. These items are the same questionnaire as Section 3.
項目３「助成対象事業」を英語で記載した場合、こちらに必ず和訳を記載してください。
事業の名称

事業の目標・目的、
実施方針

実施後に期待される効果