（様式/Form１）

家庭調書 (Record of Family)*Please fill out the required information shown inside the blue thick frame.

Name ofDepartment

Student
ID Number

About Applicant・Houshold Supporter・Household Members (excluding students)
Name

Age

From YY/MMyear
month

Name

Age

ApplicantYourself

Occupation

給給料For privately financed students, please provide information only for those living in Japan.
年金諸手当その他））

15

雑（（その他））

20

諸手当（（その他））25

雑（（その他））

30

諸手当（（その他））35

雑（（その他））40

諸手当（（その他））

45

雑（（その他））50

諸手当（（その他））55

雑（（その他））

60

諸手当（（その他））65

雑（（その他（（））

70

与給
与外営業等

給

給料

配当・譲渡年金

与Occupation

From YY/MMyear
month

Name

Age

給与外営業等給

給料配当・譲渡年金

与Occupation

From YY/MMyear
month

Name

Age

給与外営業等給

給料配当・譲渡年金

与Occupation

From YY/MMyear
month

Name

Age

給与外営業等給

給料配当・譲渡年金

与Occupation

From YY/MM
year
month

NameAge

給与外営業等給

給料配当・譲渡年金

与Occupation

From YY/MMyearmonth

給与外営業等

配当・譲渡

Please fill in the highlighted section by selecting a number from the options to the right.

Commute Classification
Yourself

115

Name122

Student

1. National
2. Public
3. Private
130

129
1. National
2. Public
3. Private

138

137
1. National
2. Public
3. Private

fathermotherSpecialdeduction

Single-parent household

People with disabilities

Official Use

228

Relationship

year
month
year
month
Name of disabilities

degreeNumber of disability certificate

1. separation 2. bereavement
1. separation 2. bereavement

Relationship

Name of disabilities

degreeNumber of disability certificate

独立生計者
221

０. 該当せず １. 該当
申請区分

給与外収入合計

給与収入合計

給与外収入合計

給与収入合計

給与外収入合計

給与収入合計

給与外収入合計

117

Commute Classification123

1. Home in Japan131

1. Elementary 2. Junior High 3. High School
4. University 5. Higher Professional School
6. Technical School (Higher Education Course)
7. Special Institute (Specialization Course)

1. Home in Japan139

1. Elementary 2. Junior High 3. High School
4. University 5. Higher Professional School
6. Technical School (Higher Education Course)
7. Special Institute (Specialization Course)
thou.
yen

1. Home in Japan

213

201

０. 該当せず
１. 該当

202

人
生活保護

222

０. 該当せず １. 該当
224

給与収入合計

1. Elementary 2. Junior High 3. High School
4. University 5. Higher Professional School
6. Technical School (Higher Education Course)
7. Special Institute (Specialization Course)

Amount ofdamage

非課税

給与外収入合計

For privately financed students, please provide information only for those living in Japan.

121

DisasterDescrip
tion

給与収入合計116
１.第一種 ２.第二種 ３.併用
４.その他（貸与 or 給付）
Classification
School Classification① 日本学生支援機構（貸与）② その他の奨学金
Name of School
Age Grade

Damage caused by disasters,windstorms, floods, theft, etc.

給与外収入合計

1. Home in Japan

前年度奨学金受給状況
Relationship

給与収入合計

家族数
218

０. 該当せず １. 該当

１.経済的理由
２.学資負担者死亡
６.学資負担者失職 ７.学資負担者長期療養 ８.非課税人
３.風水害
４.火災５.地震
９.社会的養護 １０.その他（）

（様式/Form１）

Example家庭調書 (Record of Family)*Please fill out the required information shown inside the blue thick frame.

Name ofDepartment

Student
ID Number

Graduate School of ……………………………

About Applicant・Houshold Supporter・Household Members (excluding students)
Name

Age

Occupation

35
From YY/MM2023

HU-Student

4year
month

Age

Wife

△△△ △△△
Occupation

35
From YY/MMSelf-employed
Name

2022

4year
month

Household Supporter

NameApplicant

Yourself〇〇〇 〇〇〇給Age〇〇〇〇〇〇〇

For privately financed students, please provide information only for those living in Japan.

給料年金諸手当その他））

15

雑（（その他））

20

諸手当（（その他））25

雑（（その他））

30

諸手当（（その他））35

雑（（その他））

40

諸手当（（その他））45

雑（（その他））50

諸手当（（その他））55

雑（（その他））

60

諸手当（（その他））65

雑（（その他（（））

70

与給
与
外営業等

給

給料

配当・譲渡年金

与給
与
外営業等

給

給料

配当・譲渡年金

与Occupation

From YY/MMyear
month

NameAge給
与
外営業等

給

給料

配当・譲渡年金

与Occupation

From YY/MMyear
monthName

Age

給与外営業等

給

給料

配当・譲渡

年金

与Occupation

From YY/MMyear
month

Name

Age

給与外営業等

給

給料

配当・譲渡

年金

与Occupation

From YY/MM給与外year
month

営業等

配当・譲渡

Please fill in the highlighted section by selecting a number from the options to the right.

Commute Classification
Yourself

115

1Name

Student●●● ●●●

4122

Hiroshima
elementary school

2

1. National
2. Public
3. Private

1130

129
1. National
2. Public
3. Private

138

137
1. National
2. Public
3. Private
DisasterDescription

Single-parent householdfathermotherSpecial
deduction

Damage caused by disasters,windstorms, floods, theft, etc.

People with disabilities

Official Use

228

Relationshipyearmonthyear
month
Name of disabilities

degreeNumber of disability certificate

1. separation 2. bereavement
1. separation 2. bereavement

Relationship

Name of disabilities

degreeNumber of disability certificate

独立生計者
221

０. 該当せず １. 該当
申請区分

給与外収入合計

給与収入合計

給与外収入合計

給与収入合計

給与外収入合計

給与収入合計

給与外収入合計

117

Commute Classification
123

1

1. Home in Japan139

1. Elementary 2. Junior High 3. High School
4. University 5. Higher Professional School
6. Technical School (Higher Education Course)
7. Special Institute (Specialization Course)thou.
yen

1. Home in Japan131

1. Elementary 2. Junior High 3. High School
4. University 5. Higher Professional School
6. Technical School (Higher Education Course)
7. Special Institute (Specialization Course)

1. Home in Japan

213

201

０. 該当せず
１. 該当

202

人
生活保護

222

０. 該当せず １. 該当
224

給与収入合計

1. Elementary 2. Junior High 3. High School
4. University 5. Higher Professional School
6. Technical School (Higher Education Course)
7. Special Institute (Specialization Course)

Amount ofdamage

非課税

給与外収入合計116
１.第一種 ２.第二種 ３.併用
４.その他（貸与 or 給付）
Classification
School Classification① 日本学生支援機構（貸与）② その他の奨学金
Name of School
Age Grade10

給与収入合計For privately financed students, please provide information only for those living in Japan.

121

daughter

給与外収入合計

1. Home in Japan

前年度奨学金受給状況
Relationship

給与収入合計

家族数
218

０. 該当せず １. 該当

１.経済的理由
２.学資負担者死亡
６.学資負担者失職 ７.学資負担者長期療養 ８.非課税人
３.風水害
４.火災
５.地震
９.社会的養護 １０.その他（）