平成27年度東北大学 - Tohoku University

平成２７年度
Year 2015
Application for Entrance Fee Waiver for Students
Enrolled in April/October in 2015
【注意】東日本大震災により学資負担者が被災した方を対象とした授業料免
除申請については、別の募集要項、申請書がありますので、詳細は本誌背
表紙の問い合わせ先、又は本学ホームページで確認の上、申請してくださ
い。
本誌背表紙に、注意事項が記載されていますので、申請前に必ずお読みくだ
さい。
Please make sure to read the “Important information”
on the page 15 and 16.
東北大学ホームページ
http://www2.he.tohoku.ac.jp/menjo/
東北大学
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１．申請資格 Qualified Applicants
学部新入学生
Undergraduate Students
(1) 入学前 1 年以内において、学資負担者が死亡し、又は本人若しくは学資負担者が風水害等
の災害をうけたことにより、入学料の納付が著しく困難と認められる者
Students who are recognized as having extreme difficulty in paying the entrance fee due
to the death of the person responsible for the payment of school expenses within one
year prior to admission.
(2) 上記（１）に準ずる場合であって、相当と認められる理由がある場合（例：行方不明）
Students recognized as having other circumstances equivalent to the above (1) e.g. the
missing.
大学院新入学生
Postgraduate Students
（１）本学の大学院研究科に入学を許可された者で、経済的理由により入学金を納付することが困
難であると認められ、かつ学業が優秀であると認められる者。
（２）入学前 1 年以内において、学資負担者が死亡し、又は本人若しくは学資負担者が風水害等
の災害をうけたことにより、入学料の納付が著しく困難と認められる者
（３）上記（２）に準ずる場合であって、相当と認められる理由がある場合
Students who are granted admission to the University's postgraduate school,
recognized as having difficulty in paying the entrance fee for economic reasons, and
also recognized as having outstanding academic capabilities.
 一時的に手元に現金が無いというだけでは該当しません。
Not applicable to the case of no temporary cash on hand
 また、著しく困難に該当し申請しても、必ず免除が許可されるとは限りません。
（本学での免除予算には限りがあるため、例年、ごく少数しか許可されません。）
Applicants will not always be granted the fee waiver even when they correspond to
having extreme difficulty in paying the entrance fee.
Because the amount of fee waiver is limited, only a few applicants are annually
granted the fee waiver
２．免除の取扱い Handling of Entrance Fee Waiver
(1) 申請に基づき選考機関の議を経て総長が許可します。
The entrance fee waiver will be granted by the President through the discussion of the
screening organization based on the application.
(2) 免除の額は納付すべき入学料の全額又は半額とします。
The amount which may be exempted will be the full amount or half the amount of the
entrance fee.
３．申請方法等 Method of Application, etc
(1) 申請方法 Method of application
申請書は、必ず本人が窓口へ持参し、提出してください。
※原則として、代理人による提出、郵送での申請は受け付けません。また、締切日を過ぎて
の申請はいかなる理由があっても一切受け付けませんので注意してください。
Submit the application in person (the application by proxy will not be accepted).
The application may not be accepted after the deadline for any reason.
※入院・長期出張等やむを得ない事情で期間内に本人が窓口まで提出に来られない場合は、必ず
申請締切日前日までに「学生支援課・経済支援係 ☎022-795-7816 してください。申請締切日
を過ぎての申し出は受付けません。
Consult with the Student Services Division at 022-795-7816 the day before deadline
when there are circumstances for not being able to submit the application by the
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deadline, such as being hospitalized or long-term business trip, etc. Any claim after
the deadline will not be accepted.
(２) 入学料免除申請の申請期間 Application period for the Entrance Fee Waiver
【注意！】申請期間の最終日が締切日です。締切日を厳守してください。
* The final date of the application period is the deadline. Be sure to submit the application
before the deadline.）
４月入学者
Students Enrolled in April
平成２７年３月５日（木）～平成２７年３月２７日(金) （土、日、祝日は除く。）
Thursday, March 5, 2015 – Friday, March 27, 2015
(except for Saturdays, Sundays, and public holidays)
１０月入学者 Students Enrolled in October
平成２７年８月２４日（月）～平成２７年９月２５日(金) （土、日、祝日は除く。）
Monday, August 24, 2015 – Friday, September 25, 2015
(except for Saturdays, Sundays, and public holidays)
※入学手続き時に、入学料の免除申請をすると申告した方は、必ず、上記締切日までに手続きを
行ってください。なお、締切日までに手続きを行わなかった方は、入学許可が取り消しになりま
すのでご注意ください。
When you have decided to apply for entrance fee waiver at the time of enrollment, be sure
to go through the complete procedure by the deadline above. Otherwise, your admission
will be canceled.
※例年、申請最終日は大変混み合い、２時間以上お待ちいただくこともあります。やむを得ない場
合を除き、余裕をもって早めに申請してください。
On the final day of application, you may have to wait for more than two hours. It is strongly
recommended to submit the application ahead of time to avoid the last-minute rush.
(３) 受付場所
学生支援課経済支援係（川内北キャンパス）
※受付場所は混雑状況により変更になる場合があります。HP、経済支援係窓口でご確認ください。
(４) 受付時間
月～金午前８時３０分～午後５時００分（日本時間）
Office Counter for application: Financial Support Section, Student Services Division
(Kawauchi-Kita Campus)
Open: Monday – Friday 8:30 a.m. - 5:00 p.m. (Japan Time)
Note: Submission place may be subject to change. Please check our website or contact
Financial Support Section.
※駐車スペースはありませんので、自家用車での来場はご遠慮ください。
【Note】There is no parking space available for the students.
４．入学料免除申請者の入学料納付方法について
Entrance Fee Payment for the Entrance Fee Waiver Applicants
免除申請者は、入学料の徴収が猶予されます。
The application for deferment of entrance fee payment will be accepted in addition to the
application for entrance fee waiver.
半額免除、又は不許可になった場合の入学料の納付期限は、以下のとおりです。
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When the entrance fee waiver is not approved or half the amount of entrance fee is
exempted, the deadline of entrance fee payment is as follows.
平成２７年４月入学者：平成２７年９月１５日まで
平成２７年１０月入学者：平成２８年３月１５日まで
September 15, 2015 for the students to be enrolled in April
March 15, 2016 for the students to be enrolled in October
※上記の納付日は、４月入学者、１０月入学者それぞれの最終猶予期限です。これ以後の徴収
猶予や結果通知後の分納制度はありません。希望通りの免除許可にならなかった場合に備
え、予め納付の準備をしてください。
※納付期限までに納付しない場合は、除籍となりますので注意してください。
【Note】There is no deferment or installment payment allowed after the payment
deadline above. It is strongly recommended that applicants have back up
financial arrangements for the payment in advance, in case the entrance fee
waiver is not approved.
If the payment is not made by the deadline, you will be expelled from the
university.
５．結果について Result
免除の結果は、申請時に提出された結果通知用の封筒で、４月入学者は７月中旬、１０月入
学者は１２月中旬に通知予定です。４月入学者は７月下旬、１０月入学者は１２月下旬まで
に結果通知が届かない場合は、
「学生支援課・経済支援係 ☎022-795-7816」に連絡してくだ
さい。
The result of application for tuition fee waiver will be sent in the middle of July (April
enrollment) and middle of December (October enrollment) using the envelope for
notification of results submitted at the time of application.
When the result notification is not delivered by the end of July for the students to be
enrolled in April and by the end of December for the students to be enrolled in October,
contact Financial Support Section at 022-795-7816.
６．結果に関する不服の申立 Statement of Dissatisfaction concerning the Results
入学料免除の結果に不服がある場合は、その結果の通知日から２週間以内に、学生支援課経
済支援係（川内北キャンパス）で配付する「入学料・授業料免除結果不服申立書」に不服申立ての
事由を不服の根拠となる事柄を含めて詳細に記載し、経済支援係の窓口に提出してください。入学
料・授業料免除不服申立審査専門委員会において審議のうえ、後日、結果を通知します。
なお、判定結果は、経済事情について提出された申請書類を基に十分に審査した上での判定結
果であるため、事務手続き上の瑕疵又は特別な事情がある場合を除いては、経済事情を理由とした
不服の申立を行っても判定結果が覆ることはありません。
When you are dissatisfied with the results for entrance fee waiver, describe detailed
reasons for the dissatisfaction including the matters supporting the dissatisfaction in the
"Statement of Dissatisfaction concerning the Result for Entrance / Tuition Fee Waiver"
distributed by the Financial Support Section, Student Services Division (Kawauchi-Kita
Campus) within two weeks of the notification of the result, and submit it to the window of
the Financial Support Section.
After the discussion in the meeting for the statement of dissatisfaction for entrance
/tuition fee waiver, the result will be notified.
The result will be made after screening with the financial situation based on the
documents the applicants submit. Therefore, the result of the application will not be
overturned if the Statement of Dissatisfaction concerning the Result is made for financial
reasons.
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７．個人情報の取扱いについて
Handling of Personal Information
入学料免除に関して取得した個人情報は「国立大学法人東北大学個人情報保護規程」に基
づき取扱い、当該利用目的以外には使用しません。
The personal information gathered for entrance fee waiver will be handled based on the
"Act on the Protection of Personal Information of Tohoku University" and used for the
screening process only.
「入学料免除願」及び所定用紙等は、下記ホームページからダウンロードすることもできます。
The "Application for Entrance Fee Waiver" and designated forms may be downloaded
from the following website.
掲載ＵＲＬ http://www2.he.tohoku.ac.jp/menjo/
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申請書類の準備および記入について
Preparation of the required documents and filling out the Application Form
○
４月入学者は、平成２７年４月現在で記入すること。
○ １０月入学者は、平成２７年１０月現在で記入すること。
Indicate the situation as of April 2015 for the students to be enrolled in April.
Indicate the situation as of October 2015 for the students to be enrolled in October.
「入学料免除申請に必要な書類のチェックリスト」（所定用紙）の各項目にチェックをし、提出に必要な書類
を確認してください。
Foreign students paying their own tuition must check “Checklist of Required Documents for
Entrance Fee Waiver (Designated form)”, fill out Checklist【B】, Section 1 (yellow column) and
submit the Checklist with other required documents.
１．申請書類【(1) ～ (5) は全員、(6)は該当者が提出してください。】
Documents for Application
[Items (1) to (5) must be submitted by all applicants. Item (6) must be submitted by the
corresponding applicants.]
全員が提出する書類
Documents must be submitted by all applicants
(1) 入学料免除申請に必要な書類のチェックリスト（所定用紙）
【Ａ票】一般申請者（私費外国人留学生及び独立生計者を除く）用
【Ｂ票】私費外国人留学生、独立生計者用
Checklist of Required Documents for Entrance Fee Waiver (Designated form)
Foreign students paying their own tuition
→ Fill out checklist 【B】, Section 1 (yellow column), and submit the checklist with
all required documents
(2) 入学料免除願（所定用紙）
Application for Entrance Fee Waiver (Designated form)
(3) 結果通知用の封筒【長形３号・120mm×235mm】（必要事項を記入し、８２円切手を貼ること。）
Envelope for results notification
(Enter applicant’s name, return address and student ID number, and affix an 82 JPY
stamp.)
(4) 市区町村発行の所得証明書
Income certificate issued by municipalities
Foreign Students paying their own tuition need to submit the Income
Certificate only if the family members (exclude student) are living in Japan
and have income.
４月入学者は平成２５年分（平成２５年１月～平成２５年１２月）の証明
１０月入学者は平成２６年分（平成２６年１月～平成２６年１２月）の証明
Income of January 2013 - December 2013 (issued after January 2015) for the 1st semester
Income of January 2014 - December 2014 (issued after June 2015) for the 2nd semester
※同一生計で就学者を除く家族全員分を提出してください。
※ 無職の方も提出する必要があります。
※ 私費外国人留学生は不要ですが、同居家族に収入がある場合は提出を求めることがあります。
※ 市区町村によっては（非）課税証明書では所得の証明がなされない場合がありますので、市区町
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村窓口で、使用目的（所得を証明する旨）を伝えて、適切な証明書を取得してください。
※給与所得者は源泉徴収票等（平成２６年分）を、給与所得者以外の方は確定申告書の控等（平成
２６年分）を併せて提出する必要がありますので、注意してください。（別表「平成２６年中（平成２
６年１月～平成２６年１２月）の所得・特別控除等に関する書類の内訳」参照）
(5) 奨学金（本人）の受給状況申告書（所定用紙：様式Ａ）
Statement of (student’s) Scholarship Situation (Designated form: Form A)
※受給（又は受給予定）がある場合は、受給が確認できる書類のコピーを添付すること。
（採用決定通知等、受給期間、受給金額等が記載されている通知書のコピー等）
Attach a copy of documents which indicate receiving period and monthly amount.
該当者が提出する書類
Documents that must be submitted by the corresponding applicants
This section is applicable for foreign students paying their own tuition, and only for the family
members who are living together in Japan with the applicants.
(6)
別表「平成２６年中の所得・特別控除等に関する書類の内訳」（１０ページ参照）を確認し、下記
にある所定用紙を使用して、同一生計者に対し該当するものはすべて提出してください。
【Note】Use the designated forms, and submit all the relevant documents. For foreign
students paying their own tuition should indicate the situation ONLY about the
family members who are living together with the applicants in Japan.
① 給与支払（見込）証明書（所定用紙：様式１）
給与所得者で平成２６年１月以降に新規又は中途就職者がいる場合に、勤務先が証明す
るもの。（又は、最近３か月分の給与支払明細書のコピーでも可。）
Certificate of (expected) Salary Payment (Designated form: Form 1)
To be certified by the work place for those who are salaried employees recruited
newly or started working at a different workplace after January 2014. (It may be
replaced by a copy of the payment slip for the most recent three months.)
② 退職(見込)証明書等（所定用紙：様式２）
ⅰ ４月入学は平成２６年４月１日から平成２７年３月３１日の間に、１０月入学は平成２６年
１０月１日から平成２７年９月３０日の間に、退職（見込み）者又は退職金の支払を受け
た（見込み）方がいる（退職金源泉徴収票を提出できない）場合。
ⅱ 所得証明書には収入の記載があるが、申請基準月（４月入学者は４月/１０月入学者
は１０月）において就労していない（退職先からの退職年月日の記載のある源泉徴収
票を提出できない）場合。
Certificate of (expected) Retirement (Designated form: Form 2)
i To be certified by the work place for those who retired (are expected to retire) or
received (are expected to receive) retirement allowance between April 1, 2014
and March 31, 2015 for the enrollment in April and between October 1, 2014 and
September 30, 2015 for the enrollment in October. (It may be replaced by a copy
of the withholding tax certificate for retirement allowance.)
ⅱ To be certified by employer for those who indicates income on the income
certificate but have no income at the time of application. (It may be replaced by a
copy of the withholding tax certificate which indicates the date of resignation.)
③ 長期療養者控除申立書（所定用紙：様式３）
家族に長期療養者（６か月以上）がいる場合で、医療費の控除の申立をするもの。
（なお、入院費用については、今後も入院が見込まれる場合のみで、申請時において退
院している場合は、算定できません。）※領収書のコピーを添付してください。
Request for Deduction for Persons under Long-term Medical Treatment (Designated
form: Form 3)
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To request deduction for medical expense for family members under long-term
medical treatment for more than six months (the hospital expenses may be counted
only when further hospitalization is anticipated, and may not be counted if the
relevant persons are not hospitalized at the time of application). Copies of medical
bill-payment receipts for the most recent six months must be submitted.
④ 別居世帯控除申立書（所定用紙：様式４）
家計支持者が単身赴任等で別居している場合で、光熱水料等経費の控除の申立をする
もの。※領収書のコピー、最近１か月分の給与明細書のコピーを添付してください。
Request for Deduction for Separated Household (Designated form: Form 4)
To request for deduction for utility expenses when the family finance supporter lives
separately on a job assignment, etc. Copies of utility bill-payment receipts for the
most recent six months and the most recent salary payment slip must be submitted.
⑤ 家計状況申告書（私費外国人留学生用）（所定用紙：様式５）
私費外国人留学生が申請する場合で、家計の状況を申告するもの。
Statement of the Financial Situation (To be filled out by foreign students paying their
own tuition) (Designated form: Form 5)
To state the financial situation in the application by foreign students paying their
own tuition.
⑥ 独立家計調書（所定用紙：様式６）
独立生計者（大学院学生のみ）として申請する場合で、家計の状況を申告するもの。
Independent Household Financial Record (Designated form: Form 6)
To state the financial situation in the application by persons with independent
livelihood (Japanese postgraduates only).
⑦ 留学生の住居に関する調書（私費外国人留学生用）（所定用紙：様式７）
私費外国人留学生が申請する場合で、住居について申告するもの。
※住居賃貸にかかる契約書のコピーを添付してください。
Statement for Accommodation Situation (Designated form: Form 7)
To state the accommodation situation in the application by foreign students paying
their own tuition.
Note: The contract of lease (photocopy) must be submitted
⑧ 無職・無収入に関する申立書（所定用紙：様式９）
前年の所得証明書に収入の記載があるが申請時に無職・無収入である方がいる場合に、
申立をするもの。（雇用保険受給資格証のコピー提出者を除く。）
Statement for no occupation/no income (Designated form: Form 9)
To state those who have an income in the income certificate of the previous year and
have no occupation/income at the time of application (except when submitting the
copy of the identification card of the qualified recipient of unemployment insurance
benefits).
⑨ 家族の新入学・就職先届（所定用紙：様式１０）
申請時までに「家族の入学先・就職先」が未確定の場合は、免除願書に「未定」
と記入して申請し、確定後、直ちに提出するもの。
Notification of School Enrollment and New Employment Situation of Family Members
(Designated form: Form 10)
To be submitted as soon as the "school/employment of family members" is
determined. Enter "Undetermined" in the application form when it is not
determined at the time of application.
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⑩ ＴＡ・ＲＡ等給与支払（見込）証明書（所定用紙：様式１１）
労働条件通知書・勤務時間割表等が提出できない場合に、採用期間、時間数、時給等
を、採用担当者等が証明するもの。 ※当該用紙が必要な場合、経済支援係に申し出て
ください。
Certificate of (expected) TA / RA Payment (Designated form: Form 11)
When the applicants are unable to submit the working contract or working
schedule, this form must be submitted to indicate working hours, working period
and hourly wage of TA/RA, certified by the person, faculty or office in charge.
Note: This form is available only at Financial Support Section.
⑪ Ａ４判以外の書類は、Ａ４判の所定用紙（年金書類は様式Ｃ、給与明細関係書類は様式Ｅ、
それ以外の証明書は様式Ｂ）を使用し貼付すること。
The documents of a size smaller than A4 must be attached on the designated form
(Form B, Form C and Form E).
２．申請書の記入時に留意すること
○ 病気療養等のため、介護施設等に入居し、一時別居している家族も同一世帯員に含めるこ
と。
Include family members who live temporarily in nursing facilities for medical
treatment, etc. in your household members (in Japan).
○ 独立生計として申請があっても、生計を維持するに足りる所得がないと判断される場合は、独
立生計と認められません。（学部学生は独立生計と認められません。）また、貸与型奨学金の
みで生計を立てている場合も独立生計とは認められません。
Even when an independent livelihood is stated in the application, it will not be
recognized so when it is judged that the income is not sufficient to maintain a
livelihood. (Undergraduates will not be recognized as independent livelihood.)
○ 留学生については、来日家族のみで認定します。なお、来日家族がいる場合であっても、
生活拠点が他所にあり、本人が修学のため１人で生活をしている場合は１人世帯となります。
Foreign students paying their own tuition should indicate the situation ONLY of the
family members who are living together in Japan with the applicants.
○ 私費外国人留学生、独立生計者は「自宅通学」の扱いとなります。
Foreign students paying their own tuition should choose 「１．自宅通学」in section ※
115 in the application form.
○ 追加で書類を提出する際には、書類の右上に学部（研究科）、学科（専攻）、学年、学籍番号、
氏名を記入すること。
In the upper right of other attached documents, enter your faculty (School),
department (major), year, student No. and name.
-9-
別表
平成２６年中（平成２６年１月～平成２６年１２月）の所得・特別控除等に関する書類の内訳
※以下の「区分」を確認し、該当する場合は各自書類をそろえて提出してください。
※所定用紙及び証明書以外は、コピーを提出すること。
チェックリスト【Ａ票】項目①～⑪
所得に関する証明書
Certificates for Income
【Ｂ票】独立生計者およびその家族・留学生およびその同居家族
Check List 【A】①～⑪, Checklist 【B】Foreign student who pays their own tuition fee and
their family members living together with the applicant.
区分
Classification
給与所得者
Salaried Employee
給与所得者で
平成 26 年 1 月以降
の新規・中途就職者
Salaried employee
who started
working at a new
place after January
2014
年金(恩給・遺族年
金・障害者年金等を
含む)受給者
Recipient of
Pension
(retirement
pension, survivor
pension, disability
pension etc.)
退職（予定）者
Retired Person
(Person to be
retired)
証明書の種類
Type of Certificate
源泉徴収票（平成２６年中の所得）
（所定用紙：様式 B に貼付して提出）
Withholding Tax Certificate (for
income of the year 2013)
(To be attached on the designated
form: Form B)
給与支払（見込）証明書（所定用紙：様式
１）
又は
最近３か月分の給与支払明細書
（所定用紙：様式 E に貼付して提出）
Certificate of (expected) Salary
Payment (Designated form: Form 1)
or
Payment slip for the most recent
three months (To be attached on the
designated form: Form E)
最近の払込(振込)通知書又は源泉徴収票
（平成２６年中の所得）
（所定用紙：様式Ｃに貼付して提出）
Notification of recent payment
(transfer) or withholding tax
certificate (for income of the year
2014)
(To be attached on the designated
form: Form C)
退職金源泉徴収票（所定用紙：様式 B に
貼付して提出）
又は
退職(見込)証明書等（所定用紙：様式２）
（勤務年数、退職金受領日が確認できるも
の）
Withholding Tax Certificate for
Retirement Allowance
(To be attached on the designated
form: Form B)
or
Certificate of (expected) Retirement
(Designated form: Form 2)
(That indicating the service years and
the retirement allowance receiving
dates)
- 10 -
発行元
Issued by
勤務先
Work place
備考
Remarks
長期パート勤務者を含む
Including long-term
part-timer
勤務先
Work place
都道府県市区
町村社会保険
庁等
Metropolis
and districts,
municipalities
, Social
Insurance
Agency, etc.
国民（老齢）年金・厚生年金・
恩給・扶助料・障害者年金・
農業者年金・遺族年金等
National (old-age)
pension, employee
pension, retired pension,
aid allowance, disability
pension, farmers' pension,
survivor pension, etc.
ⅰ ４月入学は平成２６年４月１日
から平成２７年３月３１日の間
に、１０月入学は平成２６年１
０月１日から平成２７年９月３０
日の間に、退職（見込み）者
又は退職金の支払を受けた
（見込み）方がいる（退職金源
泉徴収票を提出できない）場
合。
ⅱ 所得証明書には収入の記
載があるが、申請基準月
（４月入学者は４月/１０月
入学者は１０月）において
就労していない（退職先か
勤務先
Work place
らの退職年月日の記載のあ
る源泉徴収票を提出できな
い）場合
i
To be certified by the
work place for those
who retired (are
expected to retire) or
received (are expected
to receive) retirement
allowance between
April 1, 2014 and
March 31, 2015 for
the enrollment in
April and between
October 1, 2014 and
September 30, 2015
for the enrollment in
October. (It may be
replaced by a copy of
the withholding tax
certificate for
retirement
allowance.)
ⅱ To be certified by
employer for those
who indicates income
on the income
certificate but have
no income at the time
of application. (It may
be replaced by a copy
of the withholding tax
certificate which
indicates the date of
resignation.)
給与所得者以外
（事業・配当・不動産・
雑所得）の所得者、
商・工・農・林・水産等
の業種及び
その他の自営業
Other than
Salaried Employee
(Business,
dividend, real
estate,
miscellaneous etc.)
income earner,
self-employed
individual in the
industries of trade,
manufacture,
agriculture,
forestry, fisheries,
and others
廃業
Discontinued
Business
失業者
Unemployed
Person
生活保護受給世帯
Welfare Recipient
Household
児童扶養手当受給
世帯
平成２６年分所得税の確定申告書の控
又は
市区町村民税・県民税申告書の控
Copy of Final Return for the Income
Tax for the year 2014
or
Copy of Municipal/Prefectural
Inhabitant tax return
個人事業の開業・廃業等の届出書
Copy of Report for discontinuation of
the business
雇用保険受給資格証
Identification Card of the Qualified
Recipient of Unemployment
Insurance Benefits and detailed
statement indicating the dates of
payment
生活保護受給証明書等
（受給金額が確認できるもの）
Welfare Recipient Certificate, etc.
(That indicating the received amount)
児童扶養手当支給通知書
（受給金額が確認できるもの）
- 11 -
所得のある者所
持
Possessed by
the person
who has the
income
税務署又は市区町村に平成
２７年３月までに申告したもの
※電子申請等で受付印が無
い場合は、その理由を明記し
ておくこと。
Filed to the tax
authorities or the
municipalities on or
before March 2015
個人事業主所
持
Possessed by
the person
who owned
the business
公共職業安定
所
Public
Employment
Security
Office
社会福祉事務
所
Social Welfare
Office
市区町村
Municipalities
受給していない場合、無職・
無収入に関する申立書（様
式１）
Statement for no
occupation / income
(Designated Form:
Form1) need to be
submitted in the case of
not receiving benefits
母子世帯で１８才未満の子女
のいる世帯
Child Rearing
Allowance
Recipient
Household
内職者
Homeworker
保険金受取者
Recipients of
Insurance Benefits
Notification of Child Rearing
Allowance Payment (That indicating
the received amount)
雇用主（契約先）の支払証明書
Payment Certificate issued by the
employer (contractor)
保険金支払通知書又は保険金支払明細
書（受領日が確認できるもの）及び
掛金（振込保険料総額）の証明書
（保険会社が証明書を発行するもの。）
Notification or Statement of
Insurance Payment (the one
indicating the receiving dates) and
Certificate of Installment (total
amount of paid insurance premiums)
(Those for which insurance companies
issue certificates)
Single-female-parent
household with children
younger than 18 years old
勤務先・契約先
Employer
/Contractor
保険会社
Insurance
company
傷病手当受給者
Recipients of
Invalidity Benefit
傷病手当金支給決定通知書
（受給金額が確認できるもの）
Copy
of
invalidity
benefit
determination letter
(that indicates the amount of benefits
received)
全国健康保険
協会・共済組合
等
Health
Insurance
Association,
Mutual
Aid
Association,
etc.
育児休業給付金受給
者
Recipients of
Maternity benefits
育児休業給付受給資格確認通知書又は
育児休業給付金支給決定通知書（受給金
額が確認できるもの）
Copy of notification of Payment or
benefit determination letter (that
indicates the amount of benefits
received)
公共職業安定
所
Public
Employment
Security
Office
短期パート勤務者を含む
Including short-term
part-timer
４月入学者は平成２６年４月１
日から平成２７年３月３１日の
間に、１０月入学者は平成２６
年１０月１日から平成２７年９
月３０日の間に、保険金の支
払を受けた（見込み）方
Persons who received (are
expected to receive)
insurance payment
between April 1, 2014 and
March 31, 2015 for the
students to be enrolled in
April, and between
October 1, 2014 and
September 30, 2015 for
the students to be
enrolled in October
チェックリスト【Ａ票】項目⑬～⑱
特別控除に関する証明書
Certificates for Special Deduction
区分
Classification
就学者のいる世帯
（高校生以上）
Household with
family members
enrolled in school
(High school
students or higher)
障害者のいる世帯
Household with
disabled persons
介護認定３以上の人が
いる世帯
Household with
persons certified as
level 3 or higher
regarding nursing
care need
【Ｂ票】独立生計者およびその家族・留学生およびその同居家族
Check List 【A】⑬～⑱, Checklist 【B】Foreign student who pays their own
tuition fee and their family members living together with the applicants.
証明書の種類
Type of Certificate
発行元
Issued by
備考
Remarks
・在学証明書（原本）又は学生証
School Certificate or photocopy
of Student Identification Card
在学の学校
School where the
corresponding person
is enrolled
申請者本人は不要
平成２７年４月以降有効のもの
Applicant’s copy is not
necessary
Must be valid after April
2015
・障害者手帳等
Photocopy of Handbook
Disabled Persons
for
該当者所持
Possessed by the
corresponding persons
・認定書のコピー（要介護度が判別
できるページを含む）
Photocopy of the Certification
that shows the level
該当者所持
Possessed by the
corresponding persons
- 12 -
長期療養者（６か月以
上）のいる世帯
Household with
persons under
long-term medical
treatment (more
than six months)
主たる家計支持者別居
の世帯
Household where the
main family finance
supporter lives
separately
・長期療養者控除申立書（所定用
紙：様式３）
Request for Deduction for
Persons
under
long-term
Medical Treatment (Designated
form: Form 3)
病院、薬局、看護人（派
出所）等
Hospitals,
pharmacist, caregiver,
etc.
・医療支払証明書・付添料等の支払
証明書
Certificates of medical expenses,
payment of charge for helpers,
etc.
・別居世帯控除申立書（所定用紙：
様式４）
Request for deduction for
separated household
(Designated form: Form 4)
・単身赴任先の住居・光熱水料の領
収書
Receipts of housing expense and
utilities of the transferred
person
契約先
Contractor
・給与明細書（最近１か月分）
Payment slip (for the most
recent month)
火災・風水害等の被害
を受けた世帯
Household affected
by fire, storm and
flood damage, etc.
・罹災証明書、雑損控除のわかる書
類等
Affliction Certificate, documents
clarifying the deduction for
casualty loss
消防署・警察・市区町村
Fire
department,
police, municipalities
経常的に支出する費用等の最
近６か月分の支払領収書等
Receipts of payment of
ordinary expenses, etc. for
the most recent six months
（食費・ガソリン代は該当しな
い。）
経常的に支出する費用等の最
近６か月分の支払領収書等
(Not to apply to food or
gasoline cost)
Receipts of payment of
ordinary expenses, etc. for
the most recent six months
補填額（単身赴任手当）の確
認
Compensation benefits for
separated household
provided by the company
need to be declared
被害金額が確認できる書類
（家の修理費等）
Document indicating the
amount of damage (House
repairing cost, etc.)
チェックリスト【Ａ票】項目⑫
【Ｂ票】独立生計者およびその家族・留学生およびその同居家族
その他の必要書類
Other Required Documents
私費外国人留学生
Foreign students
paying their own
tuition
Check List 【A】⑫ Checklist 【B】Foreign student who pays their own tuition fee and their
family members living together with the applicants.
・家計状況報告書（所定用紙：様式５）
前期分は平成２７年４月現在の家計状況を記入すること
後期分は平成２７年１０月現在の家計状況を記入すること
Statement of financial situation (Designated yellow form: Form 5)
- Indicate your financial situation as of April 2015 the students to be enrolled in April.
- Indicate your financial situation as of October 2015 for the students to be enrolled in
October
・恒常的なアルバイト収入等がある場合は、源泉徴収票又は３か月分の給与明細書のコピー
（※同居家族に収入がある場合は、市区町村発行の所得証明書を求める場合があります。）
When you have an income from a regular part-time job, etc., be sure to submit a copy of
the Withholding Tax Certificate or payment slip for the most recent three months.
【Note】Income Certificate issued by municipalities may be asked to be submitted if
cohabiting family member(s) have income.
・預金を切り崩し生計を立てている場合は、預貯金通帳の最終記帳ページのコピーを必ず提出
When the income comes from savings, and you are depending on your savings for a living,
be sure to submit a copy of the last page of the bankbook.
※ 月の支出額×１２ヶ月分に相当する預金残高の記載が確認できなければ認められません。
(* When the income comes from your savings, your deposit balance must be larger than
the annual expenses. e.g. If you intend to use 10,000 yen/month from the savings you have
to have more than 120,000 yen in your account.)
・留学生の住居に関する調書（所定用紙：様式７）及び賃貸契約書のコピー
- The Statement of Accommodation Situation (Designated form: Form 7) and a copy of the
contract of lease.
- 13 -
ＴＡ／ＲＡ等採用者
Income from
employment as a
TA/RA
日本学術振興会特
別研究員
JSPS research
fellow
独立生計者
（日本人大学院学
生のみ）
Person with
independent
household
(Japanese
Postgraduates
only)
無職者
（前年有職者）
Unemployed
person
(Person
employed in the
previous year)
・採用通知書及び勤務時間表等のコピー
又は採用期間、時給、勤務時間数がわかる書類
A copy of the contract and schedule sheet, or documents that show working period,
working hours and hourly wage, or “Certificate of (expected) TA/RA Payment” (Designated
form: Form 11).
・採用通知書のコピー（平成 27 年度の研究奨励金支給額がわかる書類）
Copy of the Appointment Notification (Document indicating the amount of payment of
research fellowship allowance for the year 2015)
・平成 27 年度研究遂行経費申請者は、調書のコピーを必ず提出
In the case of applicants for research budget for the year 2015, be sure to submit a copy of
the investigation record.
・独立家計調書（所定用紙：様式６）
Independent Household Financial Record (Designated form: Form 6)
・所得税法上、父母等の扶養でないことがわかる書類（市区町村発行所得証明書、源泉徴収票のコ
ピー等）
Document indicating that the student is not dependent on his/her parents, etc. based on
the income tax law (Parents’ Income Certificate issued by municipalities, copy of
Withholding Tax Certificate, etc.)
・父母等の扶養となっていない本人の健康保険証のコピー
-Copy of health insurance card of the student
・配偶者の扶養に入っている場合は、それを証明できる書類
-Document indicating that the applicant is dependent of their spouse
・本人の市区町村発行所得証明書
- Income Certificate issued by municipalities of the student
・本人の住民票（世帯全員のもの） - Resident card of the student (for all family members)
・恒常的なアルバイト収入等がある場合は源泉徴収票又は３か月分の給与明細書のコピーを必ず提
出
When you have an income from a regular part-time job, etc., be sure to submit a copy of
the withholding tax certificate or payment slip for the most recent three months.
・預金を切り崩し生計を立てている場合は、預金通帳の最終記帳ページ等のコピーを必ず提出
When the income comes from savings, and you are depending on your savings for a living,
be sure to submit a copy of the last page of the bankbook.
（※月の支出額×１２ヶ月分に相当する預金残高の記載が確認できなければ認められません。）
(* When the income comes from your savings, your deposit balance must be larger than
the annual expenses. e.g. If you intend to use 10,000 yen/month from the savings you have
to have more than 120,000 yen in your account.)
・前年の所得証明書に収入があり、申請時に無職・無収入者は、無職・無収入に関する申立書（所定
用紙：様式９）を必ず提出（雇用保険受給資格証のコピー提出者を除く）
- For persons who have an income indicated in the income certificate of the previous year
and have no occupation/income at the time of application, be sure to submit the
"Statement for no occupation/income" (Designated form: Form 9). (Except for those who
submit a copy of the identification card of the qualified recipient of unemployment
insurance benefits)
教育・学生支援部学生支援課経済支援係
Financial Support Section, Student Services Division, Education and Student Support Department
※上記のほか、申請に必要な書類を求める場合があります。
Other documents may be asked to be submitted.
- 14 -
申請をする前に・・・
（必ずお読みください！）
注意事項 Important Information

申請書は、必ず申請者本人が提出してください（代理人による提出は不可）。締切日
を過ぎての申請はいかなる理由があっても、一切受付けませんので注意してください。
近年、免除申請書類を事前に連絡することなく郵送で送りつけてくる事例が多くみられます。
原則として郵送での申請は受け付けておりません。
Submit the application in person (the application by proxy will not be
accepted). The application will not be accepted for any reason after deadline.
Tohoku University shall not be responsible for any loss or trouble that the
applicant may have with mailed material. We urge all applicants to be
responsible for this matter.

免除の申請については、経済状況の悪化等により申請者が年々増加しているため、予算の都合により、
基準を満たしても許可になるとは限らない状況です。その場合、所定の入学料を納付期限までに支払
うこととなります。また、入学料免除の許可については、学生生活協議会の審議を経て決定されており、
結果が出された後は、事務手続き上の瑕疵又は特別な事情がある場合を除いては、その決定の内が
覆ることはありませんので、ご承知おきの上申請してください。
Due to the current economic situation, the number of applicants has been increasing every
year. Because the fee waiver budget is limited, only a few applicants are annually granted
the fee waiver. When the entrance fee waiver is not approved or half the amount of
entrance fee is exempted, the entrance fee payment must be made by the deadline.
The entrance fee waiver will be granted through discussion of the Student Life Association.
The decision will not be changed after the results are released, except when the special case,
such as a misstep, delinquency and/or culpability of the screening procedure are found

入学料免除の申請にあたっては、入学料を納付することが経済的理由又はその他やむを得ない事情
により真に困難かを慎重に判断してください。
The fee waiver budget is limited and only a few percent of applicants are annually granted.
Please reconsider if it is really necessary to apply for the entrance fee waiver.

免除の申請者は、結果が発表されるまで入学料の徴収が猶予されます。結果が通知されるまで入学
料を納付しないでください。
For the applicants of entrance fee waiver, the entrance fee payment will be deferred until
the results are released. Do not pay the entrance fee until notification of the results have
been received.

入院・長期出張等やむを得ない事情により申請書類を受付窓口に持参できない場合は、必ず申請期
間内に、下記問合せ先までお問い合わせください。
When you cannot submit the application to the window in person due to unavoidable
circumstances such as being hospitalized or long-term business trip, etc., be sure to consult
with the Students Service Division by the day before deadline.

家計状況等は、学生本人が正確に把握しておいてください。
Applicants must have a correct understanding of their family financial situation, etc.

提出書類に虚偽の事項を記載、又は提出書類を偽造して入学料・授業料の免除の許可を受けたこと
が判明した場合には、その許可を取り消す外、直ちに入学料を納付しなければなりません。
When false information is found in any documents or fabricated documents are submitted,
the approval of the exemption will be revoked and all fees must be repaid to the university
immediately.

不明な点については、学生本人が、下記に問合わせてください。
For any inquiries, contact Student Services Division in person.
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
免除の結果は、申請時に提出された結果通知用の封筒に入れて、４月入学者は７月中旬、
１０月入学者は１２月中旬に通知する予定です。７月下旬（４月入学者）、１２月下旬（１０
月入学者）までに結果通知が届かない場合は、下記に連絡してください。
The result of application for tuition fee waiver will be sent in the middle of July (April
enrollment) and middle of December (October enrollment), using the “envelope for
notification of results” submitted at the time of application.
When the result notification is not delivered by the end of July for the students to be
enrolled in April and by the end of December for the students to be enrolled in October,
please contact Financial Support Section at +81-22-795-7816.
Applications and Inquiries:
Financial Support Section, Student Services Division,
Education and Student Support Department, Tohoku University
41 Kawauchi, Aoba-ku, Sendai, 980-8576, Japan
Tel: +81-22-795-7816 / 795-4682
e-mail : [email protected]
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