･Submit one sheet for one household
･Fill out in a bold line area 成 月 日 申請
M F M F M F M F M F M F M F
⑨Please check the box that corresponds to your family situation.
□your own house including loan payment □ We have not registered our residency in Tokorozawa.
□living with relatives □ house for rent □ Our child is attending the school outside designated school district. □public housing(city, prefecture,etc) □ We live on government welfare program(Seikatsu-hogo)
□apartment □company house for employee □ We have members in our household with disabilities.
□ We have changes in the number of household members, and others.
2017
Financial Assistance Program
(Shugaku-enjo)
f
or elementary and junior high school students
-application
sheet-整理番号
認定年月日 月１日 認定・否認定
Date of application: Year Month Day ①Present Address:
Tokorozawa-shi,
Namiki 1-1-1 604
②Former address(as of January 1st 2017) ＊check the box
□same as above
if not, write your former address:
③Name of applicant (parents/guardians)
□male □female Date of birth: Year 1973 Month 10 Day 5
④Phone number:
090
××××
○○○○
reachable during the day
In 2016, you were: granted denied non-applied check the box
Family information:name relation date of birth employer,occupation,school name, grade,class applicant(same as ③)
father
mother Y.1973 M.10 D. 5 ○△○△ Co.,LTD.
father
mother Y.1975 M.1 D. 23 Part time jobs
son
daughter Y.2002 M.7 D. 18
Tokorozawa Junior High school 3rd grade class 2
son
daughter Y.2006 M.9 D. 12
Tokorozawa elementary school 5th grade class 1
son
daughter Y.2010 M.8 D. 1 ○△○△kindergarten
son
daughter Y. M. D.
Y. M. D.
Bank account information
name of account holder name of the bank branch name account number
in katakana letters if possible(same as ③)
トコロザワ タロウ うち
residential information check the box
1 2
¥75,000
e.g.; divorced, mother and child household…etc.
教育総務課記入欄
受付 月日 学校名 受付印
7 3 4 5 6
月 日
Taking account of exceptional circumstances, you may receive the finanacial assistance directly from the school principal.
amount of rent (month)
M
Please attach a copy of issued passbook when his/her grade is more than grade 3 for physical, more than grade B for intellectual, and more than grade 2 for mental. Points
Notice
If you have not filed your tax return (income earned January 1st through December 31st in 2016), please file your tax return. Otherwise, we will not able to condut income screening for the program. Thank you for your cooperation.
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確 認 決 定
／
／
確 認 算 定
／
／
入 力
you are required to attach the public document that states
your income and tax information record in 2016 Affidavit
To Tokorozawa Board of Education
I apply for financial assistance program. I hereby agree to the following procedures in determining to grant or deny my application.
Board of Education will inspect my income and tax information.
Receipt and settlement of expenses for school lunch will be entrusted to the school principals on my behalf.
Please write your signature ③ when you are in agreement with the conditions mentioned above.
Tokorozawa
Taro
Tokorozawa
Taro
F
Tokorozawa
Hanako
Tokorozawa
Ichiro
Tokorozawa
Jiro
Tokorozawa
Kazumi
M
M
F
