様式４(Form 4)
受験番号

申請者氏名

Examinee’s Number

Name of Applicant

給与支払（予定）証明書
Certificate of (Expected) Salary Payment
関 係各位
To whom it may concern
受給者氏名(Name of Recipient)
住所(Address)

島根大学へ入学料免除・徴収猶予申請をするため，私に支払われた（又は支払われる予定の）給与について，下記により証明願います。
I would like to have (expected) payment of salary to me certified in order to apply for admission fee
exemption/grace of payment at Shimane University.
記(Details)
１．就職年月日(Date of employment)
年Year月Month日Day

２．給与について(About salary)※最近３ヶ月の各月の総支給額（賞与，非課税所得を除く）を記入してください。
Enter the total monthly amount of payment for the latest 3 months (excluding bonus and nontaxable income).
※雇用期間が３ヶ月に満たない場合は，総支給額及び支給予定額を記入してください。
If the period of employment is less than 3 months, enter the total amount and expected amount of payment.
支給（予定）金額 ((Expected) payment)月

月

月

MonthMonthMonth円

円

円

Yen

Yen

Yen

３．賞与（ボーナス）について(About bonus)※支給する場合は，年間の総支給（予定）額又は支給（予定）月分を記入してください。
If bonus is paid, please enter the (expected) total annual amount of money to be paid or how many months’ worthof the salary it will be (expected).
※支給しない場合は，「賞与支給（予定）無」を○で囲んでください。
If not paid, circle “No (expected) bonus”.
賞与支給（予定）有年間円

又はAnnual amountYenOR(Bonus is expected to be paid.)
年間ヶ月分

Number of months, multiple ofwhich bymonthly salary is annual bonus payment.

賞与支給（予定）無No (expected) bonus

上記のとおり証明します。
I hereby certify as above.
年月日

YearMonthDay（給与支払責任者）(Responsible person in charge of payment of salary)
所在地
Location

事業所名
Name of the enterprise

氏名Name㊞
Seal

記入された情報は，入学料免除・徴収猶予業務のために利用します。その他の目的には利用しません。
The information obtained here is used for the process of admission fee exemption/grace of payment. It is not used for other purposes.

様式４(Form 4)-----以下，申請者記入欄--------------------------------------------------------------------------------Below, to be entered by the applicant.

下記の該当する計算式から年間所得金額を計算してください。計算後は，家庭調書【様式2-2】の「給与所得収入額」の「給与・賃金」欄に記入してください。
Calculate the annual amount of income using the appropriate formula below. After calculation, transcribe the amount into thecolumn “Salary/wages”in “Salary Income Amount” in the Record of Household Finances [Form 2-2].
なお，月の途中からの採用，勤務日数・時間数が通常より少ないなどの理由により，他の月額との差が大きい月がある場合は，通常勤務の2ヶ月により計算してください。
If there is a month in which the amount of income differs greatly from other monthly income, because the employment
started in the middle of the month and work days/hours were smaller than those in the usual month, or due to similarreasons, calculate the income for the usual two months.
１．賞与「有」，「年間賞与総支給（予定）額」に記載がある場合
If bonus is “paid” and there is a description in the column “(Expected total annual amount” then use the following
formula（３ヶ月分の合計金額

÷ ３） × 12 + 年間賞与総支給（予定）額 ＝Total sum of 3 months’payment(Expected) annual payment of bonus

円
Yen

２．賞与「有」，「年間賞与支給（予定）月分」に記載がある場合
If the bonus is “paid” and there is a description in the column “Number of months, multiple of which by monthly salaryis annual bonus payment.“, then use the following formula.
（３ヶ月分の合計金額
Total sum of 3 months’payment÷ ３） × ［12 +年間賞与支給（予定）月分(Expected) number of months for bonus

］ ＝円
Yen

３．賞与「無」の場合
If no bonus is paid, then use the following formula.
（３ヶ月分の合計金額
Total sum of 3 months’payment÷ ３） × 12 ＝円
Yen

記入された情報は，入学料免除・徴収猶予業務のために利用します。その他の目的には利用しません。
The information obtained here is used for the process of admission fee exemption/grace of payment. It is not used for other purposes.