Provide the address of the head of household as listed in the resident record.

Make sure that your name and address are correct,and contact the call center if you find any discrepancies.

Enter the date on which the application has been filled out.

The head of household should write their name as it is listed inthe resident record in their own hand here.

The head of household should affix their seal or provide theirsignature in this field.

DOB of the head of household (in the YYYY/MM/DD format).

Provide a phone number at which you can be reached during work hours.

List all members of your household that are eligible for the special cash payment.

State the relationship between you and other members of your household eligible for the special cash payment (from your point of view).

DOB of all members of your household eligible for the special cash payment(in the YYYY/MM/DD format).

For every eligible person, check the left box if they would like to receive the special cash payment. Alternatively, if they would like to opt out of receiving this payment, please check the box on the right.

Please indicate how you would like to receive this payment:① Via bank transfer to a financial institution② Via bank transfer to the Japan Post Bank③ At a service desk (only if you do not have any bank accounts)

If you would like to receive your special cash payment via bank transfer to a financialinstitution, provide the following information as listed on your bankbook or ATM cash card:

① Beneficiary Name (Applicant or Representative) in Katakana② Name of Financial Institution③ Branch Name④ Account Type (circle one) Left: 普通 Ordinary Deposit Account

Right: 当座 Current Account⑤ Financial Institution Code⑥ Branch Code⑦ Account Number (aligned to the right)

①② ③

④ ⑤ ⑥ ⑦

If you would like to receive your special cash payment via bank transfer to the Japan Post Bank, provide the following informationas listed on your bankbook or ATM cash card: ① Beneficiary Name (Applicant or Representative) in Katakana② Code (if you have a six-digit code, provide the sixth digit after zero) ③ Account Number

① ② ③

〒650-8570神戸市中央区加納町６－５－１

KOBE TARO 様

EXAMPLE

５ １５

ＫＯＢＥ ＴＡＲＯ

コウベ タロウ ＫＯＢＥ

１９９０/１２/３１

０７８ ３３１ ８１８１

〒650-8570神戸市中央区加納町６－５－１

ＫＯＢＥ ＴＡＲＯ

ＫＯＢＥ ＨＡＮＡＫＯ

世帯主

妻

子ＫＯＢＥ ＩＣＨＩＲＯ

✓

✓

✓

コウベ ハナコ六甲 三宮

1 1 1 1 1 1 1 1 1 1 1 1 1

✓

1990/12/31

1989/10/28

2015/3/15

①

②

③ ④

⑤ ⑥ ⑦

Please attach a copy of one of the following ID documents for the head of household: Driver’s License / Driving History Certificate / ResidenceCard / Special Permanent Resident Certificate / Passport / Personal Number Card (front side) / Basic Resident Register Card with Photo / PensionBook / Health Insurance Card / Latter-Stage Elderly Health Insurance Card / Long-Term Care Insurance Card / Identification Booklet for Persons withPhysical Disabilities and other photo IDs issued by government and public offices, as well as Public Assistance Certificates for Late-Night andHoliday Hospital Visits.

For applications filed by representatives, please include copies of ID documents for both the head of household and the representative, as well as adocument explaining the relationship between them.

If you would like to receive the special cash payment via bank transfer, please attach a copy of your ATM cash card or bankbook page that wouldallow us to verify the beneficiary name, financial institution, branch name/code and beneficiary account number.

* For Japan Post Bank, please make sure to copy the entire first spread of your bankbook.* If you only have a virtual bankbook, print out a page featuring the beneficiary name,

financial institution, branch name/code and beneficiary account number.* Write the applicant’s name on the back of all attached documents.

The above section should be filled out for applications filed by a representative or in case a representativewill be receiving the special cash payment on behalf of the applicant. Please provide the following information:① Name of the representative ② Phone number at which they can be reached during work hours③ DOB of the representative in Japanese era* format ④ Address of the representative⑤What you would like for this representative to do instead of you (options, top to bottom: File an Application / Receive the Payment / Both)⑥ Name of the head of household in their own handwriting ⑦ Seal or signature of the head of household

*Japanese eras: 1867 - July 29, 1912: 明治Meiji 1 - 45 July 30, 1912 - December 24, 1926: 大正 Taisho 1 - 15December 25, 1926 - January 7, 1989: 昭和 Showa 1 - 64 January 8, 1989 - April 30, 2019: 平成 Heisei 1 - 31

Please note that only those who fall into the following or similar categories may use a representativeto file an application or receive this payment. For more information, please contact the call center.・ Bedridden people or those suffering from dementia, if they live in a single-member household・ Persons living in elderly care facilities, orphanages, infant homes and mental health residential facilities・ Victims of domestic violence, etc.

記入例EXAMPLE

ＫＯＢＥ ＨＡＮＡＫＯ

コウベ ハナコ

２ 10 28

〒650-8570

神戸市中央区加納町６－５－１

０９０ １１１１ １１１１

✓ ＫＯＢＥ ＴＡＲＯ

ＫＯＢＥ

(２０２１年１月１日)