To the director of Kushiro tax office

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
restoration 2 8 6 6 5 5
Total Amount of special tax
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
name of CPTA 22 Ban Chi 2 Chome Kitamachi, Nakashibetsu-cho, Shibetsu-gun, Hokkaido 086-1152 [Item Regarding Payment]
Tax Counseling Corporation ORENZ Tax Office Financial Agent used for the transfer payment tax
0153-72-1212
of Income Tax and Restoration Special Income Tax
Hamanaka Machi Nogyo Kyodo Kumiai Office
with the form prescribed with the form prescribed
on article33-2 of CPTA
Transfer Date: March 20, 2017 (Thurs)
on article30 of CPTA