Date of filling in form

Daytime phone number

If your address is different to the one written in the left hand box, write in your current address in

this right hand box.

The head of the household should sign

their name here, or stamp with their

personal seal.

If anyone in the household does not want to receive the money, they should

write their name here.

If you already receive payments from the

City (eg. for child allowance etc.), then the bank account you receive the money in is printed here. If you want to receive the payment into this

bank account, you do not need to fill

anything in and you do not need any

documents to prove the bank account.

Please fill in your bank account details if you do not have an account printed in the box above, or if you wish to receive the payment into a different account. You must attach a copy of a document proving this bank account to the

back page.

If you do not have a bank account, check

this box. Payment will take between 1-2

months in this case.

Name of financial institution

Circle either1. Savings account　

(normal)2. Checking account

Name of account holder(in the box above please

write the katakana spelling ④, in the box below please

write the name as it is written on the account ⑤)

Branch name ①(If using Japan Post

Bank, this is a 3 character number)

Account number ③ (alligned to the

right)

Fill in this section if a proxy is applying.

How to fill in the Application form for Special Cash Payments in Minoh City (front page)

Branch code/number ②

Where to find bank account information on a passbookPlease note that depending on the bank, the position of this information may be slightly different.

Inside cover of passbook

Front cover of passbook

※ If there are any mistakes printed on your form, please correct them with a red pen. ※ The head of household is the person who's name is printed first on the list.

Passbook for Japan Post Bank Passbook for banks other than Japan Post

店番号　口座番号

１２３　１２３４５６７MOMIJI YUZURU 様

Front cover of passbook

Inside cover of passbook

MOMIJI YUZURU 様

お名前

モミジ　ユズル　様

店番号　口座番号

１２３　１２３４５６７

支店名

箕面支店

XXXXX XXXXXXX

お名前　モミジ　ユズル様

【店名】一二三（イチニサン）【店番】１２３　【口座番号】１２３４５６７

①

②

②

③

③

④

⑤

①

②

③

④

⑤

Attach a copy of ID confirming the identity of the head of household

• Copy of residence card• Copy of Japanese driver's license• Copy of health insurance card• Copy of My Number Card (hard plastic card, copy of front side only)• Copy of pension handbook • Copy of Japanese passport

※ Only the head of household's ID is required.※ Copy the side that shows your name and address. (If your address has changed, also attach　　the side that shows this.)※ You cannot use the My Number Notification Card (paper card).※ If a proxy is applying, they must also attach a copy of their ID.※ You can make copies at convenience stores.

Attach a copy of a document confirming the bank account from the previous page

• Copy of passbook (copy of the inside cover page)• Copy of cash card• Copy of internet banking screen

※ The copy must show the name of the bank, account number, and name of the account holder.※ If you are using the account that was pre-printed on the front page, and there are no changes 　　to the account, then you do not need to attach anything here.※ You can make copies at convenience stores.

Checklist

Check the following points, and tick ✔the box □ when you are done.□ ① Check that you have not made any spelling errors.□ ② Check that that account number written on the front page matches the account number on 　　　 the copy above.□ ③ Check that you are not missing anything from the above attached documents.

How to fill in the Application form for Special Cash Payments in Minoh City (back page)

How to fill in the return envelopeYour application must be sent in this envelope. You do not need to attach any stamps.

Make sure to check the following points ☑□　The head of household has signed or stamped the front page.□　A copy of ID confirming identity is attached.□　A copy of a document confirming bank account is attached.