Application for Gyeonggi Province

Disaster Basic Income (for non-Koreans)

※ Identification card number and issuer name below must be completed by designated on-site official

Applicant

Name

Registration No.

(Domestic Resident no.)

Mobile No.

Address of residence

Card number

Issuer

(Signature)             (Seal)

◆ Application authorization

Application Proxy

Relationship

to Applicant

Name

Address

Date of Birth

Mobile No.

Authorization

I authorize the above proxy to apply for Gyeonggi Province Disaster Basic Income (pre-paid card or on-site receipt).                                                                                        Signature or Seal

I　(the proxy) hereby apply for payment of Gyeonggi Province Disaster Basic Income (pre-paid card application and receipt) and accept the Personal Information Collection and Usage Agreement, and the usage and provision stipulations below.

◆ Information on Personal Information Collection and Usage Agreement

Collected items	Purpose	Retention period
Name, Alien Registration Number (residence report number), relationship to proxy, mobile number, address, Gyeonggi Local Currency card number, receipt payment, usage statement	Payment process for Disaster Basic Income	5 years

※ Consent to collection and use of personal information may be refused. However, if the applicant does not agree,

he/she cannot apply for Disaster Basic Income. Do you agree?                    I agree □   I do not agree □

◆ Agreement to Provision of Personal Information to Third Parties

Receiver	Provided items	Purpose	Retention period
Gyeonggi Province, Kona I	Name, Alien Registration Number (residence report number), relation to proxy, mobile number, address, Gyeonggi Local Currency card number, receipt payment, usage statement	Payment process/Local Currency pre-paid card approval	5 years

※ Consent to collection and use of personal information may be refused. However, if the applicant does not agree,

he/she cannot apply for Disaster Basic Income. Do you agree?                      I agree □  I do not agree □

Precautions and Usage Compliance

1. Use of the Gyeonggi Province Disaster Basic Income payment is limited to those businesses within the district of one’s residence. If the recipient of the payment is ineligible*, the payment will be retracted.

*Non-Korean residents residing in Gyeonggi Province as of January 19, 2021, 24:00

2. Illegal use of one’s name (unauthorized proxy) shall be punished by imprisonment for not more than five years, or a fine not exceeding KRW 10 million. <Criminal Act, Article 231 (Counterfeit or Alternation of Private Document, etc.>

3. The use of the card will be suspended and the payment will be revoked if the payment is transferred via cash/voucher or traded at a discount at businesses within the district of one’s registered residence.

4. The usage period falls within three months of the approval date. Submissions after April can be used until June 30. Any balance remaining afterwards will be recovered.

I acknowledge that I fully understand the agreement content above and hereby submit this application for Gyeonggi Province Disaster Basic Income.

Date: 2021.    .    .

Name (Proxy)                  (Signature or Seal)

Governor of Gyeonggi Province