★This is a reference translation only. Please fill in the original Japanese form.
Some translations do not fit into space provided. Please see '★Reference★' at the bottom right.

(Financial YearTo the Mayor ofMinoh City

Furigana

Address onJan. 1

Name

Current
address

As abovePhone
numberHomeMobile㊞

Date ofbirth

Y M D
本人･代理人･使者
免・個・（ ）) Municipal and Prefectural Tax Declaration (Income for the year 20

Meiji Showa
Taisho Heisei

YM

DMy Number(individualnumber))

整理番号Minoh City

Relation to headof household

Name ofrepresentative

番号確認

Relation toapplicantAddress ofrepresentative個・通住民票・システム

Do you receive an income? （ Yes ・ No ）1. Income (１)As above

If 'Yes' please fill out below, if 'No' please fill out section 7.

※If you receive dividends, capital gains, occasional income, or interest as income, please fill out section 11.
Workplace(Salary)

Workplace(\Japan Pension Service
Public pension(excluding survivor's and \)Workplace()

Total earnings from salary \\\50

Mutual Aid Association\Pension Fund\Total earnings from public pension \51

disability pension)

Ａ. Earnings \Ｂ. Necessary expenses \★ Please seereference 1)

Income Ａ-Ｂ-Ｃ

190

78

Ｂ. Necessary Expenses \Ａ. Earnings \Miscellaneous（Other than publicpension）

Ｃ. Deduction for family employees \Income Ａ-Ｂ52\\86

2. Deductions from income
Reason for loss

Date of loss

B. Amount compensatedby insurance \A. Amount of loss \Casualty loss
deductions

Balance (A-B)

145
A. Paid Medical expenses/
medicine and medical supplies \B. Amount compensated by insurance \Medicalexpense
deductions

150

151

Self medication
taxation system

150

151

Social insurance
premiumdeductions

National Health Insurance \A

Late Stage Medical Care Insurance for the Elderly \BC

General insurance \

161

162

Earthquake
insurance
premium \Earthquake insurance
premium deductions

Pension insurance \\※Those who are reporting
medical expense
deductions/self medication
taxation must attach adetailed list of particulars.

National Pension \Social insurance/continuous voluntary coverage \D

ECurrent policy contracts (since 1 January 2012)
General insurance \Former System Longterm damage
insurance premium \Pension insurance \Medical/long-term care insurance \158

157164Balance (A-B)

Long-Term Care Insurance \Former policy contracts (before 31 December 2011)

Private life
insurance
premiumdeductions

156
Small business mutual aid
premium deduction \165

159
★Reference★

Do you have any dependent relatives? ( yes ・ no ) ※If you have any dependent relatives living seperately from you, please fill out section 4 as well
Name ofspouse

Date ofbirth

Name

Otherincome\Date of birth□Under
age 16344

Name

Date of birth

My Number□Under
age 16356

Name

Date of birth

My Number□Under
age 16368

Name

Date of birth

My Number121)

Sales□
Underage 16380★ Please see reference 3)★

Please see reference 2)

Select a reason

3

Workingstudent

RelationshipLive together・seperately
RelationshipLive together・seperately
RelationshipLive together・seperately
RelationshipLive together・seperately

Please see
reference2)

Please see
reference2)

Agriculture

Physical ・ Mental ・ Rehabilitaion
level ［］② Woman who: 1) is widowed, divorced, or it3) is unclear if her husband is alive or not, 2) has
Please see
reference2)

Please seereference2)

not remarried, 3) has a dependent child in thesame household, and 4) has a total income of\5,000,000 or less

③ Man who 1) is widowed, divorced, or who it
is unclear if his wife is alive or not, 2) has not
remarried, 3) has a total yearly income of\5,000,000 or less, and 4) has a child (who is
not a dependant of anyone else) living in thesame household whose total yearly income is\380,000 or less.

★ Please see reference 4)

School name:Real estate① Woman who: 1)is widowed, divorced, or it
is unclear if her husband is alive or not, 2)has
not remarried, and 3)has a dependent, or child(who is not a dependant of anyone else) in thesame household whose total yearly income is\380,000 or less.
OR Woman who 1) is widowed or it is unclear if
her husband is alive or not, 2) has not
remarried, and 3) has a total yearly income of\5,000,000 or less\★

Pensionearnings\★

Salaryearnings★

Spouse'searnings

My Number★ Please see reference 2)★

332

Dependent relatives

Living together・apart2) Disability

My Number

Please circle theanswer thatapplies to you￥4)① Deceased Spouse ② Divorce③ Unclear if spouse is alive or not3. Earnings from wages
Those who participate in work such as day labor and part time work,
who cannot attach a tax withholding statement, please fill out below.
Phone
numberNameWork
place

Address

MonthDaily wages \7. For those who did not receive an income, circle and fill in
the relevant item below.
1 I lived on an allowance or support.
(Name of supporter)(relationship)livetogether(Address)
No. of days worked

Earnings for the month \JanFebMarAprMayJunJulAug
SepOctNovDec

2 I lived on
unemployment insurance ･ survivor's pension ･ disability pension

3 I lived on my savings.
4 Other〈reason〉

8. Method of payment for municipal and prefectural taxes
１） Please check one of the options below if you have a preference
for payment method for municipal and prefectural tax relating
to income other than that from salary or public pension (If youare under 65 years of age, it is relating to income other thanthat from salary.)

Bonus, etc.
Total
4. Dependents living seperately from you
NameAddress□

Deduct from salary (special collection)□Pay by myself (normal collection)(2) I will pay municipal and prefectural tax relating to specified
salary by myself.
□ I will pay municipal and prefectural tax relating to specified salary bymyself.
<Name of company providing main salary> (The company which provides thesalary that Municipal and Prefectural Tax will be deducted from [special collection])

5. Business tax(Those who submit this form do not need to submit a business tax declaration form)

Amount of income
Tax exempt income\Real estate income prior to special
exemption on profits and losses

Losses on transferof business asset
If business was opened orclosed in the past year

\Type of asset

Amount of losses・losses
caused by natural damage(white)\month ・ day

Opening date・
closing date

□ Office in another prefecture

6. Selection of method of taxation for listed stock
If you select a taxation method that differs to your Final Tax Return(Income Tax), please check one of the boxes below. If so, you will need
to attach a duplicate Final Tax Return Form as well as a copy of any
attached documents.
□※Municipal and prefectural tax relating to income other than from yourmain salary will be paid by normal collection (by yourself)[Notes］※Attach your tax withholding statement from all places of work (photocopyis allowed)※Depending on your amount of income/deductions, it may only be possible
to collect from your salary.
※You must file this declaration every year. If you do not, Municipal andPrefectural Tax will be deducted from your salary.

9. Donations
If you have donated to any of the following organisations, write theamount of donation below. Prefectural or local governments, Osaka
Pref. Community Chest ("Akaihane"), Japan Red Cross Society
Osaka Pref. Branch, and any donations to organisations designatedby Osaka Pref. or Minoh City.
Prefectural and local governments(Furusato Nozei)

Option to not report any listed stock for municipal andprefectural tax.

□ Option to not report the following listed stock for municipal andprefectural tax. (Any stock that is not written below will beautomatically reported.)

Osaka Prefecture Community Chest ("Akaihane"),169
Japan Red Cross Society Osaka Prefecture Branch

Donations toorganisations designatedby ordinance

Designated by Osaka
PrefectureDesignated by MinohCity

RelationshipMonthsemployed

10. Family employeeName183

My Number

Date of birth

182
181

\\\\

Type of work

Deduction for family
employee \11. Income (２)A. Earnings \Dividends
Comprehensivecapitalgains

B. Necessary expenses \83
Special deduction

Shortterm

Income A-B \Resident's tax special collection tax amount \236a94

Longtermb95

Occasional incomec89

a＋｛（b＋c）×1/2｝＝ 90Interest82※You do not need to report interest that has already had prefectural tax collected.