Japan COVID-19 ¥100,000 Payment Application Form – English Translation

氏名

==> Full Name

Notes: Write your full name in the white box.

==> Stamp Here

Notes: If you have a hanko (seal), stamp here! You can also sign your name over the 印 mark.

==> I am applying for the special fixed-benefit payment and agree to the following:

1. The municipal government may check public records in order to confirm your eligibility to receive the payment.
2. If the municipal government cannot confirm your eligibility, you may be required to submit other relevant documents as part of your application.
3. If the municipal government is not able to complete the transfer of funds to your designated bank account (for example, due to an error you made filling out the form) or the municipal government is not able to confirm the eligibility of the applicant (or designated representative of the applicant) within  three months of the starting date for the receipt of applications, your application will be considered as withdrawn.
4. If you receive a special fixed-benefit payment from another municipality, you will have to return it.

3. Check recipient information

給付対象者(下記の記載内容を御確認ください。 もし記載に誤りがあれば、朱書きで訂正してください)

==> Recipients (Please check the info below. If there is an error, please correct it in red.)

Notes: The full names of everyone in your household, their relationship to you, and their birthdates will be pre-printed on the form. In the screenshot above, Rows 1, 2, and 3 are pre-printed  with sample information for “Taro Chiyoda,” his wife and child.

• 世帯主: Head of household
• 妻: Wife
• 子: Child

Check the recipient information for yourself, the members of your household (if any), and make any corrections with a red pen.

○ 受取方法 (希望する受取方法(下記のA又はB)のチェック欄(□)に『✔』を入れて、必要事項を御記入ください。)

4.1 Check Box A or B to select how you would like to receive payment

Check Box A or B below to indicate how you would like to receive payment and fill in the required information.

□ A 指定の金融機関口座(申請・受給者又はその代理人の口座に限ります。)への振込を希望

Check Box A: Transfer to designated financial institution account. You can only designate the bank account of the applicant (head of household) or a designated agent.

□ この口座が当市区町村の水道料、地方税等の引落し又は払込みに現に使用している口座であって、申請・受給者の名義で
ある場合(この場合は通帳やキャッシュカードのコピーを添付する必要はありません。) また、当該口座の確認について、水道部局、税部局等に照会を行うことを承諾します。

Check this box if the bank account you designate is in the name of the applicant (head of household) and is also the same account that is used to make automatic withdrawals to pay your water/sewage bill, to pay your local inhabitant’s tax, etc. If this is the case, you do NOT need to attach a copy of your cash card (ATM card) as part of this application. In addition, you also give consent for the municipal government to check with the water bureau, tax bureau, etc. to confirm that the designated account is your account.

Below, also check the relevant box to indicate which of the following applies to the account you designate:

(希望する口座) □ 水道料引落口座   □ 住民税等の引落口座   □ 児童手当受給口座

Requested Account

• Water/sewage automatic withdrawal account
• Local inhabitant’s tax automatic withdrawal account
• Account where child allowance is received

If you selected Box A to receive your payment, this is the section where you fill in your financial institution account information.

4.1.1 For all bank accounts other than Japan Post Bank

The top box is for all bank accounts other than Yucho (Post Office) bank accounts. Obviously, if you want to designate a Yucho Bank account, skip the top box and fill in the bottom box only.