APPLICATION FOR EXEMPTION FROM INCOME TAX FOR INSURANCE PREMIUMS / APPLICATION FOR SPECIAL EXEMPTION FOR SPOUSE IN XXXX
To: Hongo Tax Office
Name of Employer

University of Tokyo

Name of Employee

Spouse's Name
Sign or Hanko

Employer's Address 7-3-1 Hongo, Bunkyo-ku, Tokyo

Spouse's Address

Employee's Address(if it is different from employee's)

Life Insurance
Type ofinsurance

Name of insurance company

PeriodCoveredName ofContractor

Beneficiary
NameRelation

New /Old

Actual premium(Total paid - surplus)

Confirmationby employerThis form must be prepared if you wish to take a special
exemption for your spouse. However, this exemption can not betaken generally in the following situations:(1) If your income exceeds Yen10,000,000 in YYYY (i.e., gross salary
exceeds Yen12,315,790 if salary is the only source of your income.)Lifeinsurance
Deductible (up to 40,000) ①
0③(①＋②)
Deductible (up to 50,000) ②0
TOTAL (either ③or ②whichever is bigger, and up to 50,000) (A)(NEW)Total premium contracted 1/1/2012-0(OLD)Total premium contracted before 1/1/2012

CareMedic
alInsurance
TOTAL
PensionInsurance

00

Amount calculated based on formula (up to 40,000)0(B)Deductible (up to 40,000) ④0⑥0(④＋⑤)
Deductible (up to 50,000) ⑤0
TOTAL (either ⑤or ⑥whichever is bigger, and up to 50,000) (C)0
1. Exemption of life insurance and pension premiums: the both Life and Pension are Yen50,000 as a maximTotal life insurance deductible(A) + (B) + (C）up to 120,000
2. Please attach the receipt or certificate of payment.

(NEW)Total premium contracted 1/1/2012-3. Premiums paid on insurance contracts concluded with foreign insurance underwriters outside Japan are
excluded from these exemptions¥0

Earthquake Insurance & Long-term Damage Insurance
Name of the insurancecompany

Type ofinsurance

Earthquake Insurance within the actual premium (A)Earthquake insurance deductible

Notes:(3) If you claim an exemption for spouses (you can not claim both"spouses" and this "special exemption for spouses").

Spouse's Income for 2015

(OLD)Total premium contracted before 1/1/2012

Notes:(2) If your spouse's income is less than 380,000 or exceeds 760,000, thespouse is claimed as a dependent by other person; or spouse is anemployee of your own family business (blue returns or white returns).

(A) up to 50,000

PeriodCoveredFor the insured property
Name ofContractor Name of person in use Relationship

Earthquakeor Damage

Actual premium(Total paid - surplus)

Confirmationby employer

Long-term Damage Insurance within the actual premium (B)

0 + (B) up to 15,000 after calculation

0=¥0

1. Exemption of earthquake insurance and long-term damage insurance premiums:(A) Yen50,000 and (B) Yen15,000 as a maximum; with a maximum amount of Yen50,000 for (A) plus (B)
2. Please attach the receipts or certificate of payment.
3. For long-term damage insurance of which the insured period is over 10 years, the contract should be entered into on or before
December 31, 2006

Social Insurance Premium
Insurance TypeType of Income

Gross IncomeⒶ①Salary②Business③Miscellaneous④Dividend⑤Real estate⑥Retirement*⑦Other except ①－⑥ExpensesⒷNet IncomeⒶ-Ⓑ¥650,000¥0000000TOTAL¥0* Amount of exemption
Total income of spouse

Exemptionless than 380,000 yen
380,001 yen to 399,999 yen
400,000 yen to 449,999 yen
450,000 yen to 499,999 yen
500,000 yen to 549,999 yen
550,000 yen to 599,999 yen
600,000 yen to 649,999 yen
650,000 yen to 699,999 yen
700,000 yen to 749,999 yen
750,000 yen to 759,999 yen
760,000 yen or more 0 yen

0yen
380,000yen
360,000yen
310,000yen
260,000yen
210,000yen
160,000yen
110,000yen
60,000yen
30,000yen
0yen

Small Business Mutual Aid Premiums
Payee of premium

Total premium paid

Person who is insured
NameRelation

Date of BirthInsurance Type

Total premium paid

Small Business Mutual Aid Premiums
Personal Pension Premiums
Notes:¥0TOTAL
1. Insurance premiums (e.g., Japanese national health and pension scheme)
2. Please attach the receipts or certificate of payment.

Premiums for Mentally and Physically Handicapped
Dependents Mutual Relief SystemTOTAL¥0