（様式/Form３）

Income Report（１ / ２）
◆Please fill out the form based on your household situation as of the application reference date.
(April 1 for the first semester and October 1 for the second semester)◆The required documents and the amount to be filled in differ depending on the type of income.
Please check the Application Guide and example of entry when you complete this form.
◆Declaration of all income is required for the applicant and their household supporter(s).
(See the Application Guide for the definition of "household supporter").
①Scholarships
If you or your spouse are any scholarship recipient, fill out the form and submit a copy of the scholarship certificate showing the name of recipient, the amount and the duration of scholarships.

PeriodAY20232023.4～2024.3

AY20242024.4～2025.3

Yourself

SpouseYourself

SpouseType(grant/loan)

Name of Scholarships

RelationshipMonthly
Amount

Start
Date～

①（）

JPY～②（）

JPY～

③（）

JPY～

①（）

JPY～②（）

JPY～③（）JPY～①（）JPY～②（）

JPY～③（）JPY～①（）JPY～②（）

JPY～③（）JPY～

EndDateStatus as of application reference date
(Receiving/ Waiting for result/ Ended)

EndDateStatus as of application reference date(Ongoing/ Ended)②Salary income (including part time jobs)
PeriodRelationship

Name

Place of Employment

Start
Date

Yearly Amount2023

2023.1～2023.122024

2024.1～2024.12Student ID Number

～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

（様式/Form３）（様式/Form３）

Income Report（２ / ２）
◆Please fill out the form based on your household situation as of the application reference date.
(April 1 for the first semester and October 1 for the second semester)◆The required documents and the amount to be filled in differ depending on the type of income.
Please check the Application Guide and example of entry when you complete this form.
◆Declaration of all income is required for the applicant and their household supporter(s).
(See the Application Guide for the definition of "household supporter").

③Income other than salary
PeriodRelationship

NameType of IncomeStart
Date

Yearly Amount2023

2023.1～2023.122024

2024.1～2024.12～JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

End
Date

Status as of applicationreference date(Ongoing/ Ended)

End
Date

Status as of applicationreference date(Ongoing/Ended)④Others（Pension / Allowances / Aid from others etc.）
PeriodRelationship

Name

Type of Income

Start
Date

Yearly Amount2023

2023.1～2023.122024

2024.1～2024.12Student ID Number～

JPY～

JPY～

JPY～

JPY～

JPY

～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

（様式/Form３）

ExampleIncome Report（１ / ２）

◆Please fill out the form based on your household situation as of the application reference date.
(April 1 for the first semester and October 1 for the second semester)◆The required documents and the amount to be filled in differ depending on the type of income.
Please check the Application Guide and example of entry when you complete this form.
◆Income declaration is required only for the applicant and their household supporter(s).
(See the Application Guide for the definition of "household supporter").
①Scholarships
If you or your spouse are any scholarship recipient, fill out the form and submit a copy of the scholarship certificate showing the name of recipient, the amount and the duration of scholarships.

PeriodName of Scholarships

Relationship①（AY2023

2023.4～2024.3

Yourself

Spouse2024.4～2025.3

Yourself

Start
Date～

EndDateGrant-type

150,000 JPY

2023/4～2024/3Ended

2025/3

Receiving2025/3

Waiting（The decision period：）

JPY～

③（）

JPY～

①（）

JPY～

②（）

JPY～

③（）

JPY～

○○ scholarship）

Grant-type

190,000 JPY

2024/4～②（）

JPY～③（）JPY～○○ fellowship①（Spouse）

MonthlyAmount②（①（AY2024○○ scholarship

Type(grant/loan)②（）

Grant-type

250,000 JPY）

2024/4～

Status as of application reference date
(Receiving/ Waiting for result/ Ended)

In June）～

JPY

JPY before ～）Pleaseenter the amount
payroll deductions.
(ex: Amount paid column on the withholding tax certificate)③（②Salary income (including part time jobs)
PeriodRelationship

Name

Place of Employment

myself〇〇〇〇〇〇

Part-time-job △△ Storewife△△△△△△

Part-time-job Post OfficeStartDate～EndDate

Status as of application reference date(Ongoing/ Ended)

235,698 JPY

2023/1～2023/12

Ongoing

185,622 JPY

2023/1～2023/12

Ongoing

Yearly Amount2023

2023.1～2023.12

JPY～

JPY～

JPY～

JPY
Please enter the estimated amount of income
for the～year 2024.

～

JPY

2024

myself〇〇〇〇〇〇

Part-time-job △△ Store

250,000 JPY

2024/1～2024/2Ended

myself〇〇〇〇〇〇

Part-time-job Language Tutor

320,000 JPY

2024/1～2024/12

Ongoingwife△△△△△△

Part-time-job Post Office200,000 JPY

2024/1～2024/12

Ongoing2024.1～2024.12Student ID Number

JPY～

JPY～

JPY～

JPY～

〇〇〇〇〇〇〇

（様式/Form３）（様式/Form３）

Income Report（２ / ２）
◆Please fill out the form based on your household situation as of the application reference date.
(April 1 for the first semester and October 1 for the second semester)◆The required documents and the amount to be filled in differ depending on the type of income.
Please check the Application Guide and example of entry when you complete this form.
◆Income declaration is required only for the applicant and their household supporter(s).
(See the Application Guide for the definition of "household supporter").

③Income other than salary
PeriodRelationship

Name

Type of Income

2023

2023.1～2023.12

Start
Date

Yearly Amount

～

JPY～

JPY～

JPY～

JPY～

End
Date

Status as of applicationreference date(Ongoing/ Ended)～
Please enter the estimated amount of income for theyear 2024.
JPY

2024

2024.1～2024.12

JPY～

JPY～

JPY～

JPY

～

JPY～

JPY～

JPY

～

④Others（Pension / Allowances / Aid from others etc.）
PeriodRelationship

Name

Type of Incomewife△△△△△△

Child Rearinng Allowance

Yearly Amount240,000 JPY

2023

2023.1～2023.12StartDate～

EndDateStatus as of applicationreference date(Ongoing/ Ended)

2023/1～2023/12

Ongoing

JPY～

JPY～

JPY～

JPY～

Please enter the estimated amount of incomeyear 2024.
JPY for the ～～JPYwife△△△△△△

Child Rearinng Allowance

240,000 JPY

2024

2024.1～2024.12Student ID Number

2024/1

～

JPY～

JPY～

JPY～

JPY～

JPY～

JPY～

2024/12〇〇〇〇〇〇〇

Ongoing