To the director of Kushiro tax office X

Income tax and

29 year 3 month 1 5 day The year 2 8 in Heisei era The final tax return of (form B)
special tax for restoration

domicile kana
or
0 8 8 1 3 6 0
office, 6 Sen 52, Chanai Nishi, Hamanaka-cho, name ITOU KOUJI
business
place, Akkeshi-gun, Hokkaido sex Occupation trade name name of householder
relationship to
temporary your householder
DAIRY FARMING KOUJI
residence M F SELF

residence as of phone
Jan 1st SAME AS ABOVE birth date
3 5 7 5 1 number 0153-65-2190
specific if you don't need
In Japanese yen type Blue separate loss farmer ID
0 1 2 9 1 5 2 0 this form next year
amendment
farmer
other than agriculture Tax Taxable income
26
business
25or Sheet 3 1 1 8 2 3 0 0 0
amount imposed on column26
agriculture 27
18 9 2 0 0 1 1 0 or column86 in Sheet3 3 5 8 3 0 0
Real estate Credit for dividends 28

E Interest 29
A
type
7 1 6 4 5
Credit for loans
R Dividends type 30
relating to a dwelling
N
Employment Credit for contributions 31

I 33

T Credit for
N Public pensions type
35

Miscella A special housing 37

G Balance of above
neous Others X 38
S 3 2 0 0 27-28-29-30-31-32-33-35-36-37 2 8 6 6 5 5
Capital
Short term Credit for disasters 39
gains A
(aggregate Long term M Balance of above 40
) O 2 8 6 6 5 5
Total Amount of special tax
restoration
Occasional 41
U basis for the special tax38-39 6 0 1 9
N amount of income
other than agriculture 42
business T special tax for restoration 2 9 2 6 7 4
agriculture Credit for foreign taxes type 43
1 6 1 4 1 4 2 4
Real estate Deduction for withholding tax 44
I
Balance of above
Interest 45
N
(Tax amount) 42-43-44 2 9 2 6 0 0
C Estimated tax prepayment
Dividends 46
O ( 1st and 2nd installment)
M Employment Final(3rd) payable 47
E installment
2 9 2 6 0 0
Miscellaneous Refund 48
3 2 0 0 (45-46)
Capital gains&occasional
Total amount of spouse's income 49
1/2
Total Sum of 50
1 6 1 4 4 6 2 4
Salary( exemption) for family employees

D
Casualty loss O Special exemption for Blue return 51
E
T
1 7 6 4 0 0 0 0
Withholding tax for
D Medical expense 52
U
9 5 9 7 0 H miscellaneous/occasional income 6 5 0 0 0 0
Public insurance premiums E Amount of unpaid withholding tax 53
C 2 8 9 0 7 4 0 R
T Carried loss,
Small business mutual aid premiums 54
I
8 4 0 40 0 0 S
which is deducted this year
Income amount
Life insurance premiums 55
O 9 0 0 0 0 subject to the Average taxation
N Fluctuating or
Earthquake insurance premiums 56
2 4 1 2 0 extraordinary income
type

Donations POST Tax amount paid by 3/15 57

F
PONE
0 0
R
Widows / Widowers Tax amount paid by 5/31 58
O 0 0 0 0 MENT 0 0 0
M Working students / Disabled Please note that you shall fill column41, the special tax for
0 0 0 0
Spouses( special ) type
21 restoration
I 22 0 0 0 0
N Dependents 23
0 0 0 0
bank branch
C Where to
ordinary current tax saving
Basic Exemption 24
3 8 0 0 0 0 receive postbank account type
O
M your refund
Total Sum of 24 25
4 3 2 0 8 3 0
account ID
E

Kitamachi, Nakashibetsu-cho, Shibetsu-gun, Hokkaido 086-1152

Tax Counseling Corporation ORENZ Tax Office
0153-72-1212
 [Item Regarding Payment]
Financial Agent used for the transfer payment tax
of Income Tax and Restoration Special Income Tax
Hamanaka Machi Nogyo Kyodo Kumiai Office
with the form prescribed with the form prescribed
on article30 of CPTA on article33-2 of CPTA
Transfer Date: March 20, 2017 (Thurs)