Application Form for Special Cash Payments*

Basically, this form needs to be filled in by the applicant, the head of household.

Example【Front】
２●●

１① Fill in the date of application.
Year:2/Month/Day
0000001001③ Check the names of eligible
recipients and total amount of cash
payments.

0000001② If the address has changed, delete
previous address with two lines and0 0 0 0 0current
0 0 0 0 0 1address.
0 0 0 0 0 0Write
0 0 0 0 1phone number.
write② Write the full name of the head of household inprint and affix personal seal.
Katakana name is already printed here.

２大野城 太郎

３丁目８番３号
０９２ ５０１ ２２１１

大野城レ
レ
レ

３④ Tick this box to receive the cashpayments by bank transfer.

レ⑤ Choose Bank or Japan Post Bank and fill in with relevant
information such as bank name, branch name, account number and nameof account holder that the cash payments will be transferred.

４レ

Name in Katakana

Bankオオノジョウ

Bank NameJapan Post Bank

５Branch Name

4 5 6 7 8 9 0Branch Code

Account Number

Code Number⑥ Only when applied by a representative on behalfof the head of household, fill in here.

タロウ

大野城 太郎Name of Account Holder*
Exactly the same name as the namewritten in the bankbook.

Name of Account Holder*
Same as the above.

Account Number

Date of Birth of Representative
Year/Month/Day

Full name in Katakana

６

Address of Representative
Full Name of Representative

Relationship with the Head of Household

Choose and circle one that applies.
・Application and Claim・Receipt・Application, Claim and Receipt

Items Applied byRepresentative*

Continue on the reverse,

Phone Number of Representative

Name of the Head of Household and Personal Seal➐～➒.*Do not send the original ones.

*

Attach copies of 2 documents (a copy of the document to identify the applicant and a copyof the applicant’s bankbook (the page that the relevant information such as account numberiswritten) on this side.

【Back】⑦ Attach a copy of the document to identify theapplicant, the head of household (and therepresentative only when applied by therepresentative on behalf of the head ofhousehold.)

７

Attach one of the documents listed below.
◆ a copy of Residence Card
◆ a copy of Driver’s License◆ a copy of My Number Card
◆ a copy of Health Insurance Card
◆ a copy of Pension Book
*Attachthedocumentthatshowsapplicant’s name, date of birth andcurrent address.
*

In the case that current address is written
on the back of the document such as
driver’s license, attach copies of theboth side of it.
⑧ Attach a copy of applicant’s bankbook. (Thepage that the relevant information such asaccount number is written.)
Attach a copy of applicant’s bankbook,ATM card or printed screen of an online
banking service that shows the transfer
account that you designated on the front
for the cash payments.
◆ Bank name, branch name, accountnumber and name of account holder arerequired.

８⑨ Make sure whether all necessary
information is filled and attached.

９レ
レ

レ

Make sure whether you filled in and attached allnecessary information.
Check List (Tick the boxes.)□① The form is completed with relevant
information and there is no mistake.
□② A copy of applicant’s bankbook is attachedand the information is the same as the one whichis written on the front.
□③ All necessary documents are attached.