Form 2-1

Record of Household Finances (Admission Fee Exemption/Grace of Payment)
Student Number

Kana (Ruby)

Examinee’s Number

Name

The columns “Salary Income” and “Income from other than salary” should be written with a pencil based on the total of the amount in “Breakdown ofIncome” in Form 2-2.

(1) Concerning the Applicant

Note: Write the applicable number in the column * .

NameRelationship

AgeOccupation

Place of Work etc.

Salary Income(tax included)

Income from other than salary(tax included)(Unit: 1000 Yen)

(Unit: 1000 Yen)

YearMonthYearMonthApplicantSpouse

ApplicantPeriod ofService* The way to commute* Scholarship Entitlement

1: From Home
2: From Other than Home(e.g. boarding house)

JASSO 1: Loan without interest 2: Loan with interest
3: Combination
Other 4: scholarship name(

Expected annual amount of moneyfrom non-refundable scholarship(Unit: 1000 Yen))

(2)Parents
Name

Relationship

AgeOccupation

Place of Work etc.

Period ofService

Salary Income(tax included)

Income from other than salary(tax included)(Unit: 1000 Yen)

(Unit: 1000 Yen)

Year
MonthYear
MonthFatherMother(3）Family excluding students
NameRelationship

Note: Describe all members sharing living expenses excluding (1)(2)(4).
Salary Income
Period ofAge
Occupation Place of Work etc.
(tax included)Service

Income from other than salary(tax included)(Unit: 1000 Yen)

(Unit: 1000 Yen)

Year
MonthYear
MonthYear
MonthYear
Month(4）Students

Note: Write the applicable number in the columns * .
Classification ofEstablishment

Relationship

Name(5）Special Deduction
Single-parent
householdHousehold witha disabled person

Classification of Establishmentof the Attending School(Name of School)

The way tocommute**
1：National School 1: Elementary School2: Junior High School
3: High School
4: University
2：Public School
5: Technical college
6: Specialized training college (upper secondary)
3：Private School 7: Specialized training college (post secondary)

Last year’s Status ofTuition Fees Exemption*
1: From Home

0: no exemption
1: total exemption
2: half exemption
3: partial exemption

2: From Otherthan Home(e.g.boardinghouse)（Name of school）（Name of school）（Name of school）（Name of school）*
The first
semester*
The secondsemester

Annual tuitionfee beforeexemption(Unit: 1000 Yen)
※Fill-out only ifyou getexemption

Note: Fill-out the column with * with applicable number of persons.
Fatherless Bereaved (YearMonth) Lifelong separation (YearMonth)Motherless Bereaved (YearMonth) Lifelong separation (YearMonth)

Relationship（Relationship（Relationship（） Name（） Name（） Name（Approval byUniversity

0: Refusal
1: Approval） Entitlement of Pension for the Disabled: Yes / No*） Entitlement of Pension for the Disabled: Yes / No） Entitlement of Pension for the Disabled: Yes / No
Cost of damage
Degree of damage(Unit: 1000 Yen)

Household sufferedfrom disasters
Disaster (YearMonth)such as fire, wind,Degree of Damage
water or theft etc.
Note: Enter the number of family members in (6), and applicable numbers in (7)Do not fill-out the columns (9), (10), (11), which are University use.(★)(6）The number of family members.
(7）Household on Welfare(10）Self-supporting student (★)(11）Classification of Application (★)※Incl.Applicant(8）Household with no residents tax
0: not-applicable(9）Household with multiple children (★)
1: applicable
0: not-applicable
1: applicable
1: General 2: circs (death of the party responsible for payment of school expenses)
3: circs (disaster) 4. circs (other)

0: not-applicable
1: applicable
0: not-applicable
1: applicable

The information obtained here is used for the process of admission fee exemption/grace of payment. It is not used for other purposes.