経 費 支 弁 書
LETTER OF FINANCIAL SUPPORT日本国法務大臣 殿
TO: MINISTER OF JUSTICE IN JAPAN国籍
NATIONALITY
生年月日
BIRTH DATE

志願者氏名
NAME OF APPLICANT年YEAR

月MONTH日DAY

性別
SEX

男
MALE・女FEMALE

私は、このたび、上記の者が在留中または入国した場合の経費支弁者になりましたので、下記のとおり経費支弁の引き受け経緯を説明するとともに、経費支弁について誓約いたします。
I am supporting the aforementioned applicant during his/her stay in Japan, and therefore, I would like to explain the reasons formy support and make the following statement.
記
１．経費支弁の引き受け経緯（申請者の経費の支弁を引き受けた経緯及び申請者との関係について具体的に記載してください。
）
REASON FOR THE SUPPORT (Explain the circumstance and the relationship between yourself and the applicant in detail.)

２．経費支弁内容
CONCEPT OF SUPPORT
私は、上記の者の日本国滞在について、下記のとおり経費支弁することを誓約します。
また、上記の者が在留期間中更新許可申請を行う際には、送金証明書又は本人名義の預金通帳（送金事実、経費支弁事実が記載されたもの）の写し等で、生活費等の支弁事実を明らかにする書類を提出します。
I hereby solemnly undertake to support the above applicant during his /her stay in Japan. Should the applicant apply for renewalof residency, I will submit the following documents: a copy of certificate of remittance or a bank account in his/her name, in which
the fact of remittance or support are stated, and which can prove the fact that his/her living expenses are being supported.
記（１）学 費TUITION（２）生活費LIVING EXPENSES円
JPY

毎 月 ／ 半年ごと ／ 年 間
MONTHLY／SEMI-ANNUALLY／ANNUALY
月
額MONTHLY AMOUNT円
JPY（３）支弁方法（送金・振込み等支弁方法を具体的にお書き下さい。
）
METHOD OF SUPPORT (Explain concretely the method of remittance, transfer, etc)

経費支弁者 SUPPORTER
職業（勤務先）OCCUPATION(COMPANY)
勤 務 先 住 所
COMPANY ADDRESS
現 住 所
ADDRESS
年
収（A YEARLY INCOME
氏名(署名)NAME(SIGNATURE)

電話TEL.

電話TEL.
円）㊞(SIGN)

学生との関係RELATIONSHIP WITHTHE APPLICANT

この書類は経費支弁者本人が記入してください⤒ ㈝ ᨭ ᘚ ᭩
LETTER OF FINANCIAL SUPPORT・黒のボールペンで記入してください
・修正液・修正テープの使用は不可です᪥ᮏᅜἲົ኱⮧ Ẋ
TO: MINISTER OF JUSTICE IN JAPANᅜ⡠NATIONALITY⏕ᖺ᭶᪥BIRTH DATEᚿ㢪⪅ẶྡNAME OF APPLICANTᖺYEAR

᭶MONTH

᪥DAY

ᛶู
SEX

⏨
MALE

࣭

ዪ
FEMALE

↑本人の国籍・氏名・生年月日・性別を記入⚾ࡣࠊࡇࡢࡓࡧࠊୖグࡢ⪅ࡀᅾ␃୰ࡲࡓࡣධᅜࡋࡓሙྜࡢ⤒㈝ᨭᘚ⪅࡟࡞ࡾࡲࡋࡓࡢ࡛ࠊୗグࡢ࡜࠾ࡾ⤒㈝ᨭᘚࡢᘬࡁཷࡅ⤒⦋ࢆㄝ᫂ࡍࡿ࡜࡜ࡶ࡟ࠊ⤒㈝ᨭᘚ࡟ࡘ࠸࡚ㄋ⣙࠸ࡓࡋࡲࡍࠋ
I am supporting the aforementioned applicant during his/her stay in Japan, and therefore, I would like to explain the reasons formy support and make the following statement.
グ㸯㸬⤒㈝ᨭᘚࡢᘬࡁཷࡅ⤒⦋㸦⏦ㄳ⪅ࡢ⤒㈝ࡢᨭᘚࢆᘬࡁཷࡅࡓ⤒⦋ཬࡧ⏦ㄳ⪅࡜ࡢ㛵ಀ࡟ࡘ࠸࡚ලయⓗ࡟グ㍕ࡋ࡚ࡃࡔࡉ࠸ࠋ㸧REASON FOR THE SUPPORT (Explain the circumstance and the relationship between yourself and the applicant in detail.)

経費支弁者が日本語で記入できない場合は母国語で記入してください㸰㸬⤒㈝ᨭᘚෆᐜ
CONCEPT OF SUPPORT⚾ 経費支弁者氏名 ࡣࠊୖグࡢ⪅ࡢ᪥ᮏᅜ⁫ᅾ࡟ࡘ࠸࡚ࠊୗグࡢ࡜࠾ࡾ⤒㈝ᨭᘚࡍࡿࡇ࡜ࢆㄋ⣙ࡋࡲࡍࠋࡲࡓࠊୖグࡢ⪅ࡀᅾ␃ᮇ㛫୰᭦᪂チྍ⏦ㄳࢆ⾜࠺㝿࡟ࡣࠊ㏦㔠ド᫂᭩ཪࡣᮏேྡ⩏ࡢ㡸㔠㏻ᖒ㸦㏦㔠஦ᐇࠊ⤒㈝ᨭᘚ஦ᐇࡀグ㍕
ࡉࢀࡓࡶࡢ㸧ࡢ෗ࡋ➼࡛ࠊ⏕ά㈝➼ࡢᨭᘚ஦ᐇࢆ᫂ࡽ࠿࡟ࡍࡿ᭩㢮ࢆᥦฟࡋࡲࡍࠋ
I hereby solemnly undertake to support the above applicant during his /her stay in Japan. Should the applicant apply for renewalof residency, I will submit the following documents: a copy of certificate of remittance or a bank account in his/her name, in which
the fact of remittance or support are stated, and which can prove the fact that his/her living expenses are being supported.
グ㸦㸯㸧Ꮫ ㈝TUITION㸦㸰㸧⏕ά㈝LIVING EXPENSESẖ ᭶ 㸭 ༙ᖺࡈ࡜ 㸭 ᖺ 㛫MONTHLY㸭SEMI-ANNUALLY㸭ANNUALY●,●●●,●●●

෇
JPY●●●,●●●෇JPY᭶㢠MONTHLY AMOUNT㸦㸱㸧ᨭᘚ᪉ἲ㸦㏦㔠࣭᣺㎸ࡳ➼ᨭᘚ᪉ἲࢆලయⓗ࡟࠾᭩ࡁୗࡉ࠸ࠋ㸧METHOD OF SUPPORT (Explain concretely the method of remittance, transfer, etc)

経費支弁者が日本語で記入できない場合は母国語で記入してください⤒㈝ᨭᘚ⪅ SUPPORTER⫋ᴗ㸦໅ົඛ㸧
OCCUPATION(COMPANY)໅ ົ ඛ ఫ ᡤ
COMPANY ADDRESS⌧ ఫ ᡤADDRESSᖺ཰㸦A YEARLY INCOME↓経費支弁者の情報を記入してください㟁ヰTEL.

㟁ヰTEL.
෇㸧 経費支弁者が海外在住の場合は日本円に換算して記入Ặྡ(⨫ྡ)NAME(SIGNATURE)※経費支弁者が本人であれば、本人の情報を記入

॓(SIGN)Ꮫ⏕࡜ࡢ㛵ಀ
RELATIONSHIP WITH
THE APPLICANT

印鑑がなければ経費支弁者のサイン