Application for Special fixed benefit 特別定額給付金申請書

宛て先 亀山市長 様 申請日 2020年year

5月month

20日d a y

English 英語版

SAMPLE 記入例

Ⓐ

Ⓑ

Ⓖ

Ⓗ

Ⓙ Ⓘ

Ⓚ

Seal if you have

Ⓛ

Ⓐ Date of Submittion

Confirmation

Ⓑ Resisted Adress

Ⓒ Name in Katakana or Alphabet

Ⓓ Date of Birth

Fill in

Ⓔ Head of Household’s Full name

(Same name as a Residence card’s

name) and Seal

ⒻTelephone (Available # during day time)

No need to fill

Ⓖ Check ☑ if atached copy of

identity verification document após anexar todas as cópias exigidas

ⒽCheck ☑ if all family informations (Full

Name, Date of Birth, Relationship)

are correct

If incorrect, rewrite it in red letters

※Account of Bank

Ⓚ Name of Bank Ⓛ Name of branch

Check ☑ account type

Ⓜ Ardinary account

Ⓝ Checkingaccount ⓄAccount number

※Account of Post Office

Ⓘ Number of Branch Ⓙ Number of Book

Ⓒ Ⓓ

Ⓔ

Attention !!

If check here, it means no need benefit.

Ⓜ Ⓞ

Ⓝ

Check ☑

Fill your name in Katakana if possible

Ⓕ

Paste a Copy of Head of householder’s

Identity verification document

Example: Zairyū Card (Residence card)

Deriver’s license

Driving history certificate

My Number Card with photo

Health insurance card

Etc.

※ Be clear Your name, Date of birth and

Adress

If applying by representative, paste both of

identity verification documents,

Paste a Copy of Document that

has Payment account information

①

②

③

Confirm following items and check ☑

① Confirm if filling all neccesarry

informations and they are correct

② Confirm the number of bank book that

you filled and you pasted are matched

③ Confirm all necessarry ducuments are

attched or not

Attention ! ! ※ Only one Account number must be available

※ Applications can only be sent by mail or online

To prevent the spread of the new coronavirus, Municipal office and AIAI do not support to apply

in our office.

More information, please call

Interpreter Telephone Portuguese Spanish English Yasashii nihongo

NISHI 0595 – 84 – 5008

O O

OZAWA O O

NOZAKI 0595 – 82 – 9990 O O O

SÍLVIA 0595 – 84 – 3311 O O O

TAKAMURA 0595 – 84 – 5009 O O

Kameyama municipal office

Paste Copies of required documents

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