浜松日本語学院 経費支弁書 – Pledge Form

Pledge Form
To: The Minister of Justice, Japan
Name ofApplicant
Date of Birthof Applicant
Genderof Applicant

Nationalityof Applicant//Year Month Day□ Male□ Female

I declare myself to be the financial sponsor of the above person during his/her present stay in Japan. Please find below an
explanation of my reasons for undertaking this role as well as verification of financial details.

１．Reasons for Becoming Financial Sponsor(Please explain the circumstance in concrete details for undertaking the role of financial sponsor and the relationshipbetween you and the applicant.)

２．Contents of RemittanceI testify the following financial commitments of the above person during his/her stay in Japan. In addition, in the casethat the above person applies for permission to extend the period of stay, I will submit a copy of the certification ofremittance or the bank statement for the account under my name as proof of payment of living expenses or other.
Tuition Fee

600,000JPY（１ year ）Living Expenses (per month)

JPY

Method of Payment(Please indicate specifically theprocedures of remittance, transfer andother methods of payment.)

Date/
Year/
MonthDay

SponsorName(in block letters)（Signature or Seal ）(Signature)

Address
Phone
NumberRelationship

21

重要書類
※経費支弁書追加項目

You need this document to issue a visa, please be sure to hand in this document.

滞在費の支弁方法等 Method of support to meet the expenses while in Japan.
（１）支弁方法及び月平均支弁額 Method of support and an amount of support per month(average).
□

本人負担円

□

海外からの送金円

Self

Yen

Remittance from abroad

Yen※ How much is the student's own expense from savings※How much do parents, brothers, and relatives of theearned by the job or part time job at student's country.

student send money to student? (Please write an amount per(Please write the cost per month.)month.) And how much can financial sponsor send money for

For example, if the student's share of expenses is

the student every month. (Students have to deposit that

600,000yen in all, write "50,000yen per month" here.

money in a bank, because they need to hand in copy of abankbook to Immigration Bureau when they renew theirstatus of residence.)□ 外国からの携行円 （携行者Carrying from abroad

Yen※How much Japanese Yen does the student

携行時期

WhoWhen"Who" is Basically a student.

When does the student come to Japan.

have when she or he come to Japan.

□ 在日経費支弁者負担円

Supporter in JapanYen※If there is a supporter in Japan, please write how muchthe supporter's share of expenses is.

□奨学金

円

ScholarshipYen※If the student has scholarship, please write an
amount of scholarship per month.

(Please write the cost per month.)

□ その他

円

OtherYen※If the student wants to do a part time job, please write "about 70,000Yen".

（２）経費支弁者 Supporter□

氏名Name※The name of the supporter.

□

住所

電話番号

Address

Telephone No.

※Address and Telephone No. of the supporter.

□

職業（勤務先の名称）

電話番号

Occupation(place of employment)

Telephone No.

※Occupation (place of employment) of the supporter.

□

年収Annual income

Telephone No. of the supporter’s place of work.

円
Yen※An annual income of the supporter.（convert into Japanese Yen）
Please write the exchange rate.

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Signature）