葛飾区長 あて
To the Mayor of Katsushika
住基カード Do you have a Basic Resident Registration Card?
Yes No
Yes
No
Yes No
Yes No
Yes No
Ｙｅ ｓ Ｎｏ
□ □
□ □
□ □
□ □
□
【届出に必要なもの】
＊ 記載内容に不明な点がある場合等は、ご連絡する場合があります。
＊
If there is flaw or unclear points on this Moving-out Notification, we might call to the above day time phone number.
届出日 平成 年 月 日Date of Application Heisei Year Month Date
住基カード 『有』 が一人でもいる場合は下記のチェックをお願いします。
If you answer “yes” to all of the following items 1-4, you can complete Moving-In Notification
procedures using a Basic Resident Registration Card rather than being issued a Moving-Out
Certificate and completing the ordinary Moving-In Notification procedures. Please bring a
Basic Resident Registration Card when completing Moving-In Notification procedures in your
new municipality.
３、I will complete Moving-In Notification procedures in a new municipality using a family
member’s Basic Resident Registration Card and I know the PIN for this card.
４、I will complete Moving-In Notification procedures within 14 days of moving in.
１、I can bring a Basic Resident Registration Card that has not been lost or damaged when
completing Moving-In Notification procedures.
Moving-out Notification (by Mail)
届出人氏名 Person who submitted
Moving-out Notification (署名又は記名押印) (Signature or Seal)
転
出
届 （ 郵
送
用 ）
5
有 ・ 無
旧住所 Old Address
(in Katsushika City)
氏 名 (フリガナ) Name (Katakana)
生年月日
Date of Birth
2
3
西暦AD 年 月 日
西暦AD 年 月 日
平成
年
月
日
Heisei year month date
世帯主 Head of Household
世帯主 Head of Household 異動年月日 Moving Date
(転出日) （Moving-out Date）
フリガナ Katakana
新住 所 New Address
(After Moving-out from Katsushika City)
(転出 先住所) (New Address)
葛飾区
Katsushikaku
※Basic Resident Registration Cards of persons moving-out are necessary for Moving-In Notification procedures at the new municipality. Please ensure you do not lose your Basic Resident Registration Card or mistakenly send it with this written notification.
電話番号 Phone number (日中の連絡先) (Day time phone number)
携帯・勤務先・自宅 （ ） ― Ｍｏｂｉｌｅ・Ｏｆｆｉｃｅ・Ｈｏｕｓｅ
②A copy of driving license, residence card or special permanent resident certificate, insurance copy etc.
③Envelope for return mail with 82yen stamp glued on it. ＊ Delivery is possible only to one of your addresses (old or new address)
○送付先 Contact address 〒１２４−８５５５ 〒１２４−８５５５
葛飾区立石５−１３−１ 葛飾区役所 戸籍住民課 住民記録係 Katsushikaku Tateishi ５-１３-１
電話 Tel ０３-３６９５−１１１１（代表/Main） 内線２２５３∼５ Inhabitants Register , Family REgister and Resident Section ０３-５６５４−８１９２（直通/Direct） Katsushika City office
【Documents Required for Notification】
①This Moving-out Notification(Fill inside black thick line)
＊ ③ is not required for persons moving overseas.
西暦AD 年 月 日
西暦AD 年 月 日
（印）
２、I or another household member moving out will complete Moving-In Notification
procedures with a Basic Resident Registration Card.
異 動 者
P e r s o n
M o v i n g -o u t
