I apply to the Student Support Emergency Benefits from the Japan Student Services Organization (hereinafter referred to as the "Organization").If I am currently a scholarship recipient of the Organization, I agree my account information held by the Organization to be used as payee information for the Student Support Emergency Benefits.

①

１．Basic information

２．Payee information※ No need to fill in if you are a scholarship recipient of the Organization. However, even ifyou are a scholarship recipient of the Organization, if you have any difficulty in receivingStudent Support Emergency Benefits due to reasons such as cancellation of the bankaccount registered with the Organization, please fill in. (Regarding the bank accountregistered with the Organization, it is necessary to submit the change notification separately).

②

①

②

〔Translation_【様式１】page1 〕※This document cannot be used as application forms.（Only Translation）

Please use the Japanese version [ 様式１】and 【様式２】of the application forms.

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３．Things to notify ※You can write this column either in Japanese or English.※ Please write if there are things to notify to the university, etc., such as reasons why it is difficult to submit

a certificate(s), that you have multiple children or you are in a single-parent household. However, if you write a question here, we will not reply.

※ Please describe such circumstances in detail if you have lost your part-time job opportunity in the first year at a university, etc.

４．Submitting documents※ Input "○" in the "Check" columns of the documents you are submitting. If the document(s) you are

submitting is not listed here, write the name of the submitting document(s) in brackets and input "○" in the last "Check" column.

Check Name of document

Copy of deposit/savings passbook (optional)

A copy of the rental contract for the apartment, etc. (only applicable if you do not live in a family house)

Receipt certificate, etc. that shows you are receiving public support in response to the novel coronavirusdisease (COVID-19) (if available to submit)

Pay details (before pay reduction and after pay reduction) from part-time workplace (optional)

Scholarship receipt certificate or resident tax exemption certificate (if available to submit)

Others（ ）

The information you provide will be used for the Organization's Student Support Emergency Benefits. Within the scope necessary to achieve this purpose of use, the information will be provided to the Ministry of Education, Culture, Sports, Science and Technology of Japan, universities (schools), financial institutions and subcontractors as needed. However, it will not be used for any other purposes.

In addition, if there is an inquiry from an administrative institution, public interest corporation, etc. to prevent overlapping benefits (double payment), your information will be provided within an appropriate range.

③

④

⑤

③

④

⑤

〔Translation _【様式１】page2〕

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When applying to the Student Support Emergency Benefits implemented by Japan Student Services Organization, Independent Administrative Institution, regarding the application requirements ① to ⑥ (① to ⑤ and ⑦ for international students), I have confirmed the items that meet the requirements.

⑥

⑥

〔Translation _【様式２】〕

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