※ 委任状は、お手続きの委任者がすべて自筆でご記入ください。

The person who delegates the requests must complete the entire letter of proxy with his/her own hand.

委 任 状 (Date)
Letter of Proxy
次の取り扱いを委任します。I delegate the request as follows.
郵便番号 Postal Code（ − ）
委任者（名義人）

おところ
Delegator (account holder)

Address

Registered Seal/Signature
お届け印
おなまえ
Name
受任者（代理人）

郵便番号 Postal Code（ − ）

Delegatee (proxy)

おところ
Address

おなまえ
Name

Note: For passbook-type Teigaku and Time deposit, or

* Please check the appropriate boxes below. Collateral deposit, please write the certificate numbers
contained in the passbook. For National Government bearer
* Please circle the delegated service. bonds, please write the individual number on each bond.

委任する内容
Certificate （額 面）金 額
Check Delegated service 記 号 番 号 Code number number, etc.(Note) (Face value) Amount
Withdrawal of (通常 Ordinary deposit /
□ 定額 Teigaku deposit / 定期 Time deposit / ) Yen
Withdrawal of (通常 Ordinary deposit /
□ 定額 Teigaku deposit / 定期 Time deposit / ) Yen

□ Change of (住所 address / 氏名 name / 印章 seal )

Request for reissuance of (通帳等 passbook, etc. /

□ カード card )
暗証番号照会 Inquiry about a PIN/ 暗証番号誤回数消去
□ Request to reset the number of incorrect PIN entries
マイナンバーの提供 Provide Social Security and Tax
□ number information

□
□
* Please fill in the section below when requesting items regarding registered National Government bonds.
Check 委任する内容 Delegated service 国債名称 Name of Japanese Government bond 記号 Code

国庫債券 Japanese Government Bond

□ 額面金額 Face value amount 証券番号 Certificate number

Yen
(Note)
 If the request does not require a registered seal, the delegator may use any of his/her seals.
 For requests regarding National Government bearer bonds, the delegator must also write his/her passbook number in the
“Code number” column.
 A proxy following the request based on this letter of proxy must bring his/her seal and identification documents issued by
public agencies that include the proxy’s name and address.
Depending on the delegated service, the proxy may also be required to affix the delegator’s seal to other documents and
日附印

present identification documents issued by public agencies that include the delegator’s name and address.
 We may contact the delegator in person by phone to confirm the delegated service when accepting the request from the
proxy. Please note that in the case that we cannot confirm the delegation, we cannot accept the request.
 Please note that we may not be able to accept your request if the information entered is incomplete.
 Please be sure to have the account holder sign with his/her own hand.
 Please do not use an erasable ballpoint pen to fill out this form.
＜For office use＞
委任確認
備

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□確認時刻 時 分

【規程 Navi ｺｰﾄﾞ：52593 改正年月日 2021.10.1】