front and back of the card

1. Withholding tax statement
（源泉徴収票）
* If there are more than one withholding tax statements,
confirm that the years on the two statements are the same.
Paste your withholding tax statement
on this sheet, and submit it along with
the tax return.
整理
番号
Paste your withholding tax statements here.
No photocopies
Do not paste withholding tax statements of different years.
-1-
2. Copies of your residence card or alien registration certificate
(front and back of the card)
Paste copies of the identity verification
（本人の在留カード（又は外国人登録証明書）の写し）
documents on this sheet, and submit the
sheet with the income tax return.
［Front of the card］
Paste here.
［Back of the card］
Paste here.
* If the address on the withholding tax statement differs from the one on the residence card
(or alien registration certificate), receive a copy of your residence card (住民票の写し) that
shows the change of address, and paste the copy on this sheet.
Please submit this document as an appropriate tax payment procedure.
-2-
3. Identity verification documents
Paste copies of the identity verification
documents on this sheet, and submit the
sheet with the income tax return.
When you submit an income tax return on which you enter your Individual Number, you must show the identity
verification documents (a document that confirms the number and an identification document) or attach copies
of them.
If attaching copies of the identity verification documents, paste them on this sheet and submit the sheet with the
income tax return.
If you have an Individual Number Card
Paste copies of the front and back of your Individual Number Card.
(Front of Individual Number Card)
(Back of Individual Number Card)
Paste here.
If you do not have an Individual Number Card
Paste a copy of (1) a document that confirms the number and a copy of (2) an identification document.
* Please do not paste the original documents.
(1) Document confirming the number
(2) Identification document
« Copy of a document that shows the Individual
Number of the person submitting the income tax
return »
Any of:
• Notification Card
• Copy of the certificate of residence
(Only a certificate of residence that shows the
Individual Number is acceptable.)
« Copy of a document that identifies the holder of
the Individual Number entered on the income tax
return »
Any of:
• Driver’s license • Public health insurance card
• Passport
• Physically Disabled Persons’ Handbook
• Residence card
-3-
4. Proof of supporting dependent family members
（扶養親族であることの証明）
Paste copies of the identity
If you want to claim tax deduction for a spouse or other dependent verification documents on this
family members, submit the following documents. They will be used sheet, and submit the
sheet with the income tax
to determine your eligibility for a deduction.
return.
(1) If you support a family member in Japan
（扶養している親族が日本にいる場合）
Copy of the residence card or alien registration certificate of
the dependent family member
（扶養親族の在留カード（又は外国人登録証明書）の写し）
[Front of the card]
Paste here.
[Back of the card]
Paste here.
-4-
(2) If you support a family member abroad
（扶養している親族が海外にいる場合）
Paste copies of the following documents on page 8,
and submit them with the income tax return.
Attach both documents proving the family relationship and records of money
transfer.
a. Documents proving the family relationship
Either of the following documents (1) or (2)
(1) Document issued by the national or local government, such as a copy of the supplementary family
register,and a copy of the passport of the family member living abroad
(2) Full copy of the family register, birth certificate, marriage certificate, or other document
b. Records of money transfer
The following types of documents proving that you have paid for living expenses, etc. of the family
member living abroad.
(3) Documents proving that you have paid for the family member living abroad through a financial
institution (written requests for foreign remittances, etc.)
(4) Documents proving that the family member living abroad has purchased goods by credit card, and
the credit card company has received the amount for his/her purchases from you
(credit card statements, etc.)
(Notes) 1. You must submit the originals of all documents that prove the family relationship, except
the passport. You may submit a copy of reports of money transfer
in place of their originals.
Example
2. If you have multiple dependents, attach reports of money transfer
for each dependent.
Wife
Husband
3. If the above documents (1) to (4) are written in a non-Japanese
Support
×
language, attach their Japanese translation(s).
4. Two people cannot support the same dependent family member.
Child
(dependent
[Examples of necessary documents if you have a dependent family member living abroad]
* For other dependent members, paste documents which prove that they are your family.
-5-
Fill out this form referring to the sample on
page 7, and submit it with the income tax
return.
Relationship diagram of your dependent family and remittance
扶養親族等関係図及び送金先
Please note:
Example
1. Circle each dependent family member.
Put an X over the drawing of a deceased parent.
(扶養する親族を○で囲む。父母で死亡している者については、×を付ける。)
2. Write the address of each dependent family member in the box.
-
（ に扶養する親族の住所を書く。）
3. Draw an arrow indicating remittance.
City,
County,
State, USA
(送金した相手と本人を矢印で結ぶ。)
4. If there are other dependent family members, write them in the same way.
(その他の扶養親族がいる場合は、書き加える。)
父
母
Father
Mother
義父
義母
Father-in-law
Mother-in-law
私
配偶者
Myself
Spouse
Addres
Japan
子
子
子
Child
Child
Child
Please submit this document as an appropriate tax payment procedure.
-6-
Sample
父
母
Father
Mother
-
Addres
義父
Father-in-law
Mother-in-law
City,
County,
State, USA
私
配偶者
Myself
Spouse
Japan
-
義母
-
City,
County,
State, USA
子
子
子
Child
Child
Child
City,
County,
State, USA
-
-7-
City,
County,
State, USA
Paste the following documents:
1. Documents proving the family relationship
(birth certificate, marriage certificate, etc.)
2. Records of money transfer
(written requests for foreign remittance, etc.)
3. Their Japanese translation(s).
-8-
5. Receipts of medical expenses（医療費の領収書）
To claim for medical expenses deduction, submit the original
copies of the receipts. If you cannot paste all receipts on this page,
put them in an envelope, and paste the envelope on this page.
整理
番号
Paste the receipts here.
No photocopies
-9-
Paste the receipts of medical
expenses on this page, and
submit them along with the
tax return.
6. Documents to prove the National Health
Insurance or the National Pension payment
if you are paying them
（国民健康保険料や国民年金の支払いの分かる書類）
Paste the documents here.
-10-
Paste the documents on this
page, and submit them along
with the tax return.
7. Copy of front and back cover of the bankbook of the transfer account
（還付される税金の振込口座の通帳の表紙と裏表紙の写し）
Paste the copy on this page,
and submit it along with the
tax return.
整理
番号
Paste the copy of the pages which show the names of the bank,
the branch and the account holder and the type of deposit,
e.g. front and back cover of the bankbook.
Please submit this document as an appropriate tax payment procedure.
-11-