Year-End Tax Adjustment Guide for 2020

[Please check if the following

documents are enclosed]

※All of ①②③ are required to be submitted.

①【令和2年分 給与所得者の扶養控除等（異動）申告書】( Application for (Change in) Exemption for Dependents of Employment Income Earner for 2020 )

【 Certificate Envelope 】

②【令和2年分給与所得者の保険料控除申告書兼 給与所得者の基礎控除申告書兼 給与所得者の配偶者控除等申告書兼 所得金額調整控除申告書】

(Application for Deduction for InsurancePremiums for Employment Income Earner

and Application for Basic Exemption of EmploymentIncome Earner and Application for Exemption

for Spouse of Employment Income Earner and Application for Exemption of Amount of Income Adjustment for 2020 )

③【令和3年分 給与所得者の扶養控除等（異動）申告書】(Application for (Change in) Exemption for

Dependents of Employment Income Earnerfor 2021)

－1－

Please affix your seal on

①②③ and submit

・Printed information is ok！・No application for ② ！・No application for loans

relating to a dwelling

Corrections/additions in each application are acceptable ! Certificates are enclosed in the certificate envelope!

* Please enclose only certificates in the certificate envelope.

Year-End Tax Adjustment is…to settle the discrepancy between the income tax amount withheld from each salary/bonus payment throughout the year and the total income tax amount based on the annual salary/bonus payment for the year. Everybody receiving salary/bonus are required to process this year-end tax adjustment in principle.

Please mention

corrections

/additions

within

the frame

with a red pen,

or highlight the

applicable part.

e-pay Application is a system for employees to apply for personal/status changes through the web.

【If you correct/add to the printed information】When you change data including your address, name, and family data, please change your data through the web as well as

correcting/adding data in red ink on “Application for (Change in) Exemption for Dependents of Employment Income Earner for 2020”

and “Application for (Change in) Exemption for Dependents of Employment Income Earner for 2021”. Changes are not reflected in

other e-pay systems by submitting application forms alone. You have to make changes both on the web and application forms to

reflect the changed data in both your payroll and year-end tax adjustment.

For e-pay

Application

Users

【Distribution of year-end tax adjustment results】The year-end tax adjustment results of the clients, who view monthly payslips, etc. in the e-pay system, are not distributed in paper.

Please print the "Report of result content/request for correction", which can be used when there are applications

for correction/addition in application contents, from the e-pay Meisai (Slip) screen, fill in/affix a seal in the report,

and submit it by January 7 (Thu), Reiwa era 3 (2021).

【Year-End Tax Adjustment Results】The "Report of result content/request for correction", which can be used when there are applications for correction/addition

in the year-end tax adjustment results and application contents, will be viewable on the e-pay Meisai (Slip) screen

by December payroll payment.

e-pay Slip is a system to view payslips and withholding tax certificates on the screen through the web.

For e-pay

Slip Users

No Faxed/CopiedForm Accepted

Notice

【Confirmation of printed content of ①②③】

Such your own information, as address, are

printed in each document. Please confirm that

they have been not changed.

→ If there are any changes, please proceed to

the right.

【Confirmation of necessity of application for ②】

・To take a special exemption for spouse

・To take a deduction for insurance premiums

・There are incomes other than employment

income during 2020.

→ If you make an application, please proceed

to the right.

【Confirmation of necessity of special credit for

loans relating to a dwelling】

→ If you make an application, please proceed

to the right.

① As the correction/addition is necessary for

【Application for (Change in) Exemption for Dependents of

Employment Income Earner for 2020】,

please confirm the details in the second page.

② As it is necessary to fill out 【Application for Deduction for

Insurance Premiums for Employment Income Earner and

Application for Basic Exemption of Employment Income

Earner and Application for Exemption for Spouse of

Employment Income Earner and Application for Exemption of

Amount of Income Adjustment for 2020 】,

please confirm the details in the third page.

③ As the correction/addition is necessary for

【Application for (Change in) Exemption for Dependents of

Employment Income Earner for 2020】,

please confirm the details in the second page.

Please confirm the details in the fourth page, with Application for

Special Credit for Loans Relating to a Dwelling/Certificate of

Balance prepared.

・All of ①②③ are required to be submitted. The omission of those submission is

likely to cause increase of income tax amount from January in next year or additional

collection of income tax in year-end tax adjustment.

・ ①As “Application for (Change in) Exemption for Dependents of Employment

Income Earner for 2020” is only for year-end tax adjustment,

not to be reflected in your payroll. ※ In case you need to correct your or

your family's information, please take the procedure for the change of

personal information together, in the prescribed method.

・ ③As 【Application for (Change in) Exemption for Dependents of

Employment Income Earner for Reiwa era 2 (2021)】 needs to be submitted

at the time of next year's payroll calculation, please be sure to submit it.

・ Year-end tax adjustment is made for annual gross payment. In case you changed a place of

employment, we are not able to make the year-end tax adjustment, if you do not submit the

"Withholding tax certificate for employment income for 2020", issued by the previous employer.

If you still have the certificate, please submit it in a prescribed way.

※個人情報保護については、裏面をご参照ください。

Ｃ. 障害者等

明・大 ・昭・平・令

1 一般障害者 1 寡婦

2 特別障害者 2 ひとり親

（障害の程度）

（〒 ） 勤労学生 (寡婦の事由)

1.高校 （在学校名） 1 死別2.大学 2 生死不明3.その他 3 離婚

あなたに源泉控除対象配偶者・または障害者に該当する同一生計配偶者、扶養親族がいない場合には、以下の各欄に記入する必要はありません。

※源泉控除対象配偶者・同一生計配偶者の詳細については裏面をご確認ください。

(ﾌﾘｶﾞﾅ） 明・大・昭・平

（〒 ） 本人と同じ 1 一般障害者

2 特別障害者

円 3 同居特別障害者

※16歳未満の扶養親族については、扶養控除の対象とはなりませんが、地方税法の規定により申告が必要です。

(ﾌﾘｶﾞﾅ） 明・大・昭・平・令

1 一般障害者

（〒 ） 本人と同じ 配偶者と同じ 2 特別障害者

3 同居特別障害者

円

給与の支払者

の名称（氏名）

及び

所在地（住所）

従たる給与についての扶養

控除等申告書を提出してい

る場合は○印を付けてくださ

い。

給与の支払者の法人

（個人)番号

企業コード お問合せ番号

あなたの個人番号

あなたの住所又は居所

（令和3年1月2日以降）

日中問合せ先 TEL

社員番号 あなたの

生年月日

障害等の事実／障害等の内容

※該当する区分の番号をご記入ください。

フリガナあなたの氏名

印

配偶者の有無

有 　・ 　無

※現在配偶者（内縁を含

む）がいる場合、申告でき

ません

非居住者である親族

（海外居住の親族）令和3年に異動がある場合に、区分をご記入ください

妻　・　夫

※配偶者の合計所得が48万

円以下の場合、該当する区分

と障害の程度をご記入くださ

い。

住所又は居所

生計を一にする事実

Ａ．源泉控除対象配偶者・または障害者に該当する同一生計配偶者

源泉控除対象配偶者・または障害者に該当する同一生計配偶者の申告 氏名及び個人番号 あなたとの続柄 生年月日 障害者区分

老人扶養親族

令和3年に異動がある場合に、区分をご記入ください※該当する区分と障害の

程度をご記入ください

(～S27.1.1)

非居住者である親族

（海外居住の親族）

住所

又は

居所

生計を一にする事実

Ｂ．扶養親族扶養親族の申告 氏名及び個人番号 あなたとの続柄 生年月日 障害者区分

扶

※修正がない場合も押印ください。

※お問合せの際は、以下の「お問合せ番号」をお伝えください。

バーコード

w

□

令和3年分の給与(賞与)の所得税はこの申告書により計算されます。印字内容に誤りが無いかご確認の上、修正等がある場合欄内に赤ペンで追加・修正して

押印ください。

0 新たに扶養親族を追加する【結婚・離職等】（「源泉控除対象配偶者・または障害者に該当する同一生計配偶

者」を追加する）

1 右記印字対象者を扶養対象外とする【離婚・就職等】（「源泉控除対象配偶者・または障害者に該当する同一生計配偶

者」に該当しない配偶者は対象外となります）

2 昨年（令和2年）中に死亡

※ 申告される方は同封されております

お手続きの注意点、ＨＰにてご確認ください。

0 新たに扶養親族を追加する【出生・離職等】（所得見積額が48万円以下の場合のみ扶養になります）

1 右記印字対象者を扶養対象外とする【結婚・就職等】

（所得見積額が48万円を超える場合は扶養になりません）

2 昨年（令和2年）中に死亡

◇日中に連絡が取れる番号を、市外局番からご記入ください。

[ 自宅 ・ 勤務先 ・ 携帯 ]

□ □

令和3 年中の所得見積額

令和3 年中の所得見積額

給与所得者の扶養控除等（異動）申告書令和 年分 ( 2021)

この申告書は、あなたの給与について扶養控除、障害者控除などの控除を受けるために提出するものです。

この申告書は、源泉控除対象配偶者、障害者に該当する同一生計配偶者及び扶養親族に該当する人がいない人も 提出する必要があります。

この申告書は、２か所以上から給与の支払を受けている場合には、そのうちの１か所にしか提出することができません。税務署長殿

3

市区町村長殿

1 同居老親等

2 その他

※会社で定めた方法により提出した個人番号に相違ありません。

（この申告書への個人番号の記載は不要です。個人番号に変更が生じた場合、

会社の定める方法により提出してください。）

本人の個人番号の取り扱いに準ずる

年/ｙ 月/ｍ 日/ｄ

年/ｙ 月/ｍ 日/ｄ

年/ｙ 月/ｍ 日/ｄ本人の個人番号の取り扱いに準ずる

※個人情報保護については、裏面をご参照ください。

Ｃ. 障害者等

明・大 ・昭・平・令

1 一般障害者 1 寡婦

2 特別障害者 2 ひとり親

（障害の程度）

（〒 ） 勤労学生 (寡婦の事由)

1.高校 （在学校名） 1 死別2.大学 2 生死不明3.その他 3 離婚

あなたに源泉控除対象配偶者・または障害者に該当する同一生計配偶者、扶養親族がいない場合には、以下の各欄に記入する必要はありません。（※源泉控除対象配偶者・同一生計配偶者の詳細については裏面をご確認ください。）

Ａ．源泉控除対象配偶者・または障害者に該当する同一生計配偶者

(ﾌﾘｶﾞﾅ） 明・大・昭・平（〒 ） 本人と同じ

令和2年中の収入金額等 Ⓐ 必要経費等 Ⓑ 令和2年中の所得の見積額 　Ⓒ＝(Ⓐ－Ⓑ)

円 円 円

B.扶養親族 ※16歳未満の扶養親族については、扶養控除の対象とはなりませんが、地方税法の規定により申告が必要です。

(ﾌﾘｶﾞﾅ） 明・大 ・昭・平・令（〒 ） 本人と同じ 配偶者と同じ

令和2年中の収入金額等 Ⓐ 必要経費等 Ⓑ 令和2年中の所得の見積額 　　Ⓒ＝(Ⓐ－Ⓑ)

円 円 円

給与の支払者の名称（氏名）

及び

所在地（住所）

従たる給与についての

扶養控除等申告書を

提出している場合は○

印を付けてください。

給与の支払者の法人（個人)番号

企業コード お問合せ番号

社員番号 あなたの

生年月日

障害等の事実／障害等の内容

※該当する区分の番号をご記入ください。

フリガナあなたの氏名

印

配偶者の有無

有 　・ 　無

妻　・　夫

所得の

種類

生計を一にす

る事実

あなたの個人番号

あなたの住所又は居所

（令和3年1月1日時点）

日中問合せ先 TEL

配偶者　情報

異動月日及び事由 氏 名 あなたとの続柄 生年月日

※現在配偶者（内縁を含む）がいる場合、申告で

きません

扶養親族①情報

異動月日及び事由 氏 名 あなたとの続柄 生年月日 住所又は居所 障害者区分老人扶養親族

(～S26.1.1)

所得の

種類

非居住者である親族

（海外居住の親族）

生計を一にする

事実

住所又は居所 障害者区分非居住者であ

る親族

（海外居住の

親族）

扶

2

※修正がない場合も押印ください。

※お問合せの際は、以下の「お問合せ番号」をお伝えください。

バーコード

※ 申告される方は同封されております

お手続きの注意点、ＨＰにてご確認く ださい。

◇日中に連絡が取れる番号を、市外局番からご記入ください。

[ 自宅 ・ 勤務先 ・ 携帯 ]

この申告書は、あなたの給与について扶養控除、障害者控除などの控除を受けるために提出するものです。この申告書は、源泉控除対象配偶者、障害者に該当する同一生計配偶者及び扶養親族に該当する人がいない人も 提出する必要があります。

この申告書は、２か所以上から給与の支払を受けている場合には、そのうちの１か所にしか提出することができません。

税務署長殿

給与所得者の扶養控除等（異動）申告書令和 年分 ( 2020)

市区町村長殿

会社が定めた方法により提出した個人番号に相違ありません。〔この申告書への個人番号の記載は不要です。個人番号に変更が生じた場合、

会社の定める方法により提出してください〕

□

（注）

※48万円を超える場合は扶養対象外

（注）以下、二重枠箇所の項目が全て未記入の場合は、所得が無いものとして処理いたします。予めご了承ください。

（注）配偶者や扶養親族が所得金額調整控除（年金）の対象の場合、 収入金額（Ⓐ）、必要経費（Ⓑ）は記載せず、直接所得の見積額（Ⓒ）のみ記入ください。

本人の個人番号の

取扱いに準ずる

1 所得無し2 給与3 老齢・退職年金4 その他

□

（注）

本人の個人番号の

取扱いに準ずる

個人番号

(障害の程度)

①同居

老親等

②その他

個人番号 1 所得無し2 給与3 老齢・退職年金4 その他

年/ｙ 月/ｍ 日/ｄ

□

※配偶者の合計所得が48万

円以下の場合、該当する区分

と障害の程度を記入ください。

0 増（結婚・離職等）

1 減（離婚・就職等）

2 死亡

異動年月日

年 月 日

0 増（出生・離職等）

1 減（結婚・就職等）

2 死亡

異動年月日

年 月 日

①一般障害者

②特別障害者

③同居特別障害者

（障害の程度）

※該当する区分と障害

の程度を記入ください

こちらの申告書は令和2年分の年末調整用にご提出いただくものです。印字内容に誤りが無いかご確認の上、修正がある場合には必ず欄内に

赤ペンで追加・修正して捺印ください。

年/ｙ 月/ｍ 日/ｄ

①一般障害者

②特別障害者

③同居特別障害者

（障害の程度）

❶

年/ｙ 月/ｍ 日/ｄ

①令和2年分（2020） 扶養控除等（異動）申告書(Application for (Change in) Exemption for Dependents for 2020) ③令和3年分（2021） 扶養控除等（異動）申告書について(Application for (Change in) Exemption for Dependents for 2021)

Please use a red pen for corrections or additions, or color the applicable parts with markers.

－2－

Ｂ

ⒷPlease enter your telephone/cell phone number contactable in the

daytime for inquiries.

ⒸIf there are changes in an eligible spouse for tax withholding （※1）, an

eligible spouse for a disabled person in the same household （※2）, or

dependent members, from January 1, 2020 through the entry date, please

choose the following number, and enter the reason and date of change.

In case the number of an eligible spouse for tax withholding, an eligible spouse for a disabled person who lives in the same household, or dependent members increases: ………0【e.g 】 To add as dependents due to retirement, the spouse, who got married, falls under an eligible spouse for tax withholding, etc.

In case the number of an eligible spouse for tax withholding, an eligible spouse for a disabled person who lives in the same household, or dependent members decreases: ………1【e.g 】 To remove an eligible spouse for tax withholding from dependents, due to divorce. A dependent commences employment. (The income exceeds ¥480,000 ) Your income exceeds ¥9,000,000, and your spouse, currently printed, is not eligible as a disabled person, etc.

In cases an eligible spouse for tax withholding, an eligible spouse for a disabled person

who lives in the same household, or dependent members pass away within 2020 ……2

Ⓐ Your resident-registered address as of January 1, 2021

(for inhabitant tax payment from June 2021)

Ⓚ

ⒾPlease circle 有(Yes)/無(No) on having spouse.

* Whether or not your spouse is dependent.

ⒿIf you are an eligible person with disability, please be sure to enter the classification of a person with disability and the degree of disability.

ⓁIf you apply for exemption for working students, please enter applicable number from 1: High School, 2: University/College, and 3: Others and describe your school name. If you select 3, please request your school to issue both of the following documents and submit them.

①Copy of certificate from the Minister of Education, Culture, Sports, Science and Technology or the Minister of Health, Labour and Welfare②Certificate from the principal/representative of your school/vocational training organization.

ⒽPlease affix your seal. * For foreigners, please sign your name.

ⓂIf your spouse/dependent is a person with disability, please enter applicable category number.

“3. 同居特別障害者” means dependents who fall within the category of persons with special disabilities who live together permanently with the salary earner, his/her spouse, or other family members living in the same household as the salary earner.

Ｃ

ＪＫ

Ｌ

Ｎ

Ｃ

ＭＤ

Ｍ

I

株式会社 あかさたな

東京都千代田区丸の内 7 – 7 - 7△▽ビル ４Ｆ

1000 - 00025

1234567

給与 太郎

キュウヨ タロウ

北海道札幌市北区南十条 1 － 1 － 1

マンション 101

001 － 0000

給与 桃子

レキュウヨ モモコ

昭和 45 － 7 － 1

0123456789

1

昭和48－4－20

Ｎ

Ｅ

給与

0123456789

株式会社 あかさたな

東京都千代田区丸の内 7 – 7 - 7△▽ビル ４Ｆ

1000 - 00025

キュウヨ タロウ

給与 太郎

001 － 0000北海道札幌市北区南十条 1 － 1 － 1

マンション 101

昭和 45 － 7 － 1

給与 桃子

1234567

レ

昭和 48 － 4 － 20

給与

ⒹTo add dependents, please enter the dependent’s name with furigana.

For foreigners please enter the dependent’s first name and last name in

order.

ⓃPlease enter your spouse’s/dependent’s income.

Type of Income

1: No income・・・unemployed, with no other incomes from real

estates or businesses

2: Employment income・・・employees, part-timers

3: Old-age/retirement pensions・・・old-age/retirement pensioners

4: Others・・・persons who have incomes other than above 2 & 3.

Ａ Revenue during 2020・・・Please enter estimated revenue for 2020

Ｂ Necessary expenses・・・ for 2: Employment income

→ ¥550,000

（Up to employment income of ¥ 1,619,000）for 3: Old-age/retirement pensions

→depends on date of birth.

Please refer to the following:

①Born on and after January 2, 1956, with the pension income is

¥1,300,000 or less ・・・¥600,000

②For those, who were born on or before January 1,

Showa era 31 (1956), and whose annual pension income is

¥ 3,300,000 or less ・・・¥1, 100,000

for 4: Others→depends on the type of

income. Please confirm by yourself.

Ｃ Estimated income during 2020・・・above A minus B

(Spouse: If your income is ¥9,000,000 or less, and the spouse’s is ¥950,000

or less, eligible for withholding tax. Dependent: If his/her income is ¥480,000

or less, regardless of your income, eligible as a dependent.)

* For multiple incomes, please enter the amounts in separate lines.

ⒺDate of Birth

ⒻPlease fill in “Relationship with you” if you add dependents.

Ｏ

0123456789123

0123456789123

③Please fill out 【Application for (Change in)

Exemption for Dependents for 2021】 based on

your status after January 2021 according to the above.

Ｏ

Ｇ

ＤＥ

Ａ

Ｈ

＜ Note ＞ The handling of exemption

for spouse and special exemption for

spouse have been changed since

Heisei era 30 (2018). The intended

scope, requested to be mentioned in

the application for (change in)

exemption for dependents, is as

mentioned in the right table, due to

the above change. ※1. Eligible spouse for tax withholding ※2. Eligible spouse for a disabled

person who lives in the same household.

Ｆ

Ⓖ Please enter his/her address. If it is same as yours, check

“本人と同じ(same as yours)”.

ⓄIn case an eligible spouse for tax withholding, an eligible spouse in the

same household for a disabled person, or an eligible dependent for

exemption is a non-resident (Individuals who do not have addresses in

Japan, and have not had domiciles in Japan continuously for more than

one year till the present), please put a circle (○) in the “非居住者である親族(Non-resident family members) ” column. Please add the amount of

remittance, etc. in the “生計を一にする事実 (Living in the same household) ”

column. ※ In case non-resident family members are applicable, 「親族関係書類」(Family

member relationship document) and 「送金関係書類」(Remittance-related document) are

required. Please pay close attention, as the place of submission of these two are your

company's person in charge of payroll service.

Ｇ

給与 花子

キュウヨ ハナコ

23

150,000220,000

レ

①昭和 22 － 4 － 10

01 4 1

母

0✓

No Faxed/CopiedForm Accepted

From 2020 an unmarried single parent is also able to make the

application. Referring to the following table, please enter the classification

in case you fall under the widow or single parent category and the reason

also in case you fall under the widow category, in numbers. ※ If you have a

spouse (including a common-law one), you are not able to make the application.

Required or not to enteryour spouse

Estimated total amount of your income this year（Your estimated income amount, in case you haveemployment income only and are not subject to

exemption of amount of income adjustment)

9,000,000 yen or less(10,950,000 yen or less)

Over 9,000,000 yen(Over 10,950,000 yen)

Not eligibleas a disabled

person

×Not requested to be

filled in

Eligible as adisabledperson

〇Requested to be

filled in

Over 480,000 yenbut not more than

950,000 yen(Over 1,030,000 yen

butnot more than1,500,000 yen)

Over 950,000 yen(Over 1,500,000

yen)Est

imat

ed tot

al a

mou

nt o

f yo

ur s

pous

e's

inco

me

this y

ear

(Est

imat

ed a

mou

nt o

f yo

ur s

pous

e's

reve

nue

in c

ase

of e

mploy

men

t re

venu

e on

ly)

480,000 yen orless

(1,030,000 yen orless)

〇Requested to be filled in

Spouse

〇Requested to be filled in

×Not requested to be filled in

×Not requested to be filled in

×Not requested to be filled in

※1

※2

To enter in the application for deduction for insurance premiums

★ Attachment of deduction certificates for insurance premiumsThe attachment of the originals of deduction certificates for insurance premiums is necessary to take

deduction for insurance premiums. Please prepare the deduction certificates for insurance

premiums, issued by insurance companies.

★ Group contract insurance, printed in advance The attachment of deduction certificates is not required for the insurances, printed by our company

in advance. Please submit the deduction certificates, corrected with a red pen, only when the

insurance premiums are different from the printed ones due to the revisions, etc. By the way, in

case dividends, etc. are received, the less amount is printed than the insurance premiums, actually

paid.

★ Sample of deduction certificate for insurance premiums

あなたの住所又は居所　（令和3年1月1日時点）

（〒 ）

◆給与所得者の基礎控除申告書 兼 給与所得者の配偶者控除等申告書◆

　①あなたの本年中の合計所得金額の見積額

円 　　 記載がない場合は、年末調整計算にて算出した合計所得金額を、本年分の合計所得金額とします。

　②配偶者（妻又は夫）情報　　 （ 注） あなたの合計所得金額が1 0 0 0 万円を超える場合、配偶者控除・ 配偶者特別控除の対象外となり記載でき ません。配偶者の名前が印字されてい る場合は、二重線で消してください 。

(ﾌﾘｶﾞﾅ） （〒 　　 ） □本人と同じ

必要経費等 Ⓑ

円 円 円

◆所得金額調整控除申告書◆

　　　あなた自身が特別障害者　　　　　　同一生計配偶者が特別障害者　　　　　　扶養親族が特別障害者　　　　　　扶養親族が年齢23歳未満（平10.1.2以降生）（注）「同一生計配偶者」とは、あなたと生計を一にする配偶者で、本年中の合計所得金額の見積額が48万円以下の人をいいます。

※同じ世帯に所得者が2人以上いて、あなたの給与収入金額が850万円を超え、かつあなたの扶養控除等異動申告書に記載していない扶養親族がいる場合、yeta10@payroll.co.jpまでご連絡ください。

◆給与所得者の保険料控除申告書◆

円

(A) 円 旧長期損害保険料（保険期間が10年以上で、満期返戻金の支払われるもの） (B) 円

円

＊国民年金、国民年金基金・・・証明書を添付してく ださい。 合計（控除額） 円 合計（控除額） 円

独立行政法人中小企業基盤

整備機構の共済契約の掛金円

確定拠出年金法に規定する企業型・

又は個人型年金加入者掛金

心身障害者扶養共済制度

に関する契約の掛金

社会保険の種類

保険料支払先の名称

保険料を負担することになっている人

あなたが本年中に

支払った保険料の金額種類

あなたが本年中に支払った

掛金の金額区分 名称 氏名あなたと

の続柄

(最高50,000円）

円 （B)の金額が10,000円を超える場合は（Ｂ）×1/2＋5,000円 円 円

地震保険料 合計 合計

地震保険料(Ａ）の金額 (最高50,000円）

＋（Ｂ）の金額 (最高15,000円）

＝

※1　あなたが本年中に支払った

旧長期損害保険料等の金額（分配を受けた剰余金等の

控除後の金額）

給与の

支払者の

確認印

家屋等に居住若しく は家財を利用

している者又は傷害等の保険の被保

険者の氏名

あなたと

の続柄

保険会社等の名称 保険等の種類（目的） 保険期間 保険等の契約者の氏名

保険等の対象となった あなたが本年中に支払った

地震保険料等の金額（分配を受けた剰余金等の

控除後の金額）

円 円

生命保険料控除額

計（イ）+（ロ）+（ハ）

（最高120,000円）

（最高50,000円）円 ⑤と⑥のいずれか大きい金額 (ハ)

(a)のう ち新保険料等の

金額の合計額D 円

Dの金額を封筒裏の計算式Ⅰ（新保険料

等用）に当てはめて計算した金額④

（最高40,000円）円 計（④＋⑤）

円

⑥（最高40,000円）

円

(a)のう ち旧保険料等の

金額の合計額E 円

Eの金額を封筒裏の計算式Ⅱ（旧保険料

等用）に当てはめて計算した金額⑤

新　　・　　旧

新　　・　　旧

新　　・　　旧 円

円

【個人年金保険料】 年金支払

期間

保険等の契約者の氏名

保険金等の受取人年金の支払

開始年月日 新・旧の区分あなたが本年中に支払った保険料等の金額

（分配を受けた剰余金等の控除後の金額）

（ａ）

給与の

支払者の

確認印

(a)の金額の合計額 C 円Cの金額を封筒裏の計算式Ⅰ（新保険料

等用）にあてはめて計算した金額(ロ)

（最高40,000円）

保険会社等の名称 保険等の種類 氏名あなたと

の続柄

円

（最高40,000円）円

【介護医療保険料】保険期間

保険等の契約者の氏名

保険金等の受取人 あなたが本年中に支払った保険料等の金額

（分配を受けた剰余金等の控除後の金額）

（ａ）

給与の

支払者の

確認印保険会社等の名称 保険等の種類 氏名あなたと

の続柄

（ａ）のう ち旧保険料等の

金額の合計額B 円

Bの金額を封筒裏の計算式Ⅱ（旧保険料

等用）に当てはめて計算した金額②

（最高50,000円）円 ②と③のいずれか大きい金額 （イ） 円

（ａ）のう ち新保険料等の

金額の合計額A 円

Aの金額を封筒裏の計算式Ⅰ（新保険料

等用）に当てはめて計算した金額①

（最高40,000円）円 計（①＋②） ③

新　　・　　旧

新　　・　　旧

新　　・　　旧

新　　・　　旧

新　　・　　旧 円

新　　・　　旧

あなたが本年中に支払った保険料等の金額

（分配を受けた剰余金等の控除後の金額）

（ａ）

給与の

支払者の

確認印保険会社等の名称 保険等の種類 氏名あなたと

の続柄

要件

【一般の生命保険料】保険期間

保険等の契約者の氏名

保険金等の受取人新・旧の区分

本人の個人番号の

取扱いに準ずる円

〇扶養控除等異動申告書にて申告した内容に相違ありません。主たる給与収入が850万円を超え、以下の要件のいずれかを満たす場合、所得金額調整控除を申告します。

配偶者の個人番号 配偶者

の

所得の

種類

令和2年中の収入金額等 Ⓐ令和2年中の合計所得金額の見積額 Ⓒ ＝（Ⓐ－Ⓑ）

裏面の【配偶者の本年中の合計所得金額の見積額の計算】ⓑ欄の金額）配偶者控除の額又は

配偶者特別控除の額

フリガナ 印あなたの氏名

明・大 ・昭・平

生計を一にする事実

年/ｙ 月/m 日/d

税制改正により、基礎控除及び、配偶者控除又は配偶者特別控除を受けようとする場合は、この申告書に以下の必要事項を記載の上、提出する必要があります。

１ ①については裏面の【あなたの本年中の合計所得金額の見積額の計算】を使用して計算した、本年の合計所得見積額（ⓐの金額）を記載してください。

２ あなたの合計所得金額の見積額が1,000万円以下で、かつ、配偶者の合計所得金額の見積額が133万円以下である場合は、②についても記載してください。

　※この会社以外での所得がある場合、必ず合算した合計所得金額を記載してください。

配偶者の氏名 配偶者の生年月日 配偶者の住所又は居所非居住者である配偶者

(海外居住の配偶者）

給与所得者の保険料控除申告書兼給与所得者の基礎控除申告書

兼給与所得者の配偶者控除等申告書兼所得金額調整控除申告書

給与の支払者

の名称（氏名）

及び所在地（住所） お問合せ番号

企業コード社員番号

給与支払者の法人番号

配偶者控除等

保・基・配・所

バーコード

税務署長殿

※お問合せの際は、以下の「お問合せ番号」をお伝えください。

※申告や修正がない場合も押印ください。

（2020）v令和 年分2

地震保険料控除

生

命

保

険

料

控

除

1.国民年金2.国民年金基金

3.その他

※「3.その他」をご選択された方は、名称を記入してください。

社会保険料

控除

小規模企業

共済等掛金

控除

1 所得無し

2 給与

3 老齢・退職年金

4 その他

（注）

②令和2年分 保険料控除申告書 兼 基礎控除申告書 兼 配偶者控除等申告書 兼 所得金額調整控除申告書( Application for Deduction for Insurance Premiumsfor Employment Income Earner and Application for Basic Exemption of Employment Income Earner and Application for Exemption

for Spouse of Employment Income Earner and Application for Exemption of Amount of Income Adjustment for 2020 )

・If you need to correct or declare, please mention in the pertinent column, using a red pen. ・If you take basic exemption or special exemption for spouse, in accordance with tax revisions, you need to enter necessary

information in this application form and submit it. (If not entered or submitted, you might not be able to take the deduction.)

－3－

Ⓖ Deduction for social insurance premiums (Please declare, confirming the classification.)National Pension・・・1 * Certificate required.National Pension Fund・・・2 * Certificate required.Others・・・3(National Health Insurance, arbitrarily continued health insurances before changing jobs, etc.)Please enter the amount of social insurance premiums, paid by yourself during 2020. Please note that such social insurance premiums, withhold from salary/bonus/pension, as health insurance and employees' pension, are not to be entered.

Ⓗ Deduction of premiums for small enterprise mutual aid system, etc.Please enter, based on the description in the deduction certificate for insurance premiums at hand.

妻

給与 太郎 本人▽△生命 介護 10 給与 太郎 20,000

給与

株式会社 あかさたな東京都千代田区丸の内 ７ － ７ － ７ △▽ビル ４Ｆ

1000－00025

給与 太郎

0123456789123

○○生命 養老 20 48,000

▽△生命 がん 20 119,000給与 太郎 給与 桃子

妻

▽△生命 年金 10 95,000給与 太郎

30,00010個人年金◇◇生命

2.28

△△損保

○○損保 旧長期 20 12,000給与

太郎本人給与 太郎

×× 損保 地震火災 15,000

20,0005地震

48 4 20

国民年金 日本年金機構1 給与 桃子 56,000

レ

2

給与 桃子

550,000 550,000

12,000

給与

太郎

本人給与 太郎5.10

10,000

1234567

001 - 0000

0123456789

北海道札幌市北区南十条 1 - 1 - 1

マンション 101

ⒹApplication for Exemption of Amount of Income AdjustmentIt is subject to exemption, in case your main employment income exceeds ¥ 8,500,000 and

it meets a certain requirements. (※ Please refer to the application form for details.)

※ Since the calculation is made, based on the declared content in the Application for (change in)

exemption for dependents for employment income, you do not have to enter in this column, etc.

※ Please inform 【yeta10@payroll.co.jp】 by e-mail, in case there are more than one income

earner in the same household, your employment income exceeds ¥ 8,500,000, and there are

dependents, who are not declared as your deduction-eligible dependents (Not mentioned in the

Application for (change in) exemption for dependents).

Ⓕ Deduction for earthquake insurance premiums (It is necessary to enter

in the thick-frame part.）The entry column for earthquake insurance premiums is divided for 「Earthquake insurance

premiums」 and 「Old long-term nonlife insurance premiums」. Please enter, based on the

description in the deduction certificate for insurance premiums at hand. (In case one contract has

「Earthquake insurance premiums」 and 「Old long-term nonlife insurance premiums」, please

enter each insurance premium in the same line.)

Ⓐ Please enter/confirm your name and resident registered address and

affix your seal.

ⒷPlease indicate your total estimated income amount within this year.

(※ Income means the amount, with necessary expense deducted from

revenue.) For the calculation of total estimated income amount, please

use the "Calculation table of total estimated income amount", which is the

back side of the application form.

<Note>

・If your total estimated income amount is not indicated yet, we calculate it, regarding the

total income amount, calculated by this company, based on the year-end tax adjustment

result, as this year's total estimated income amount.

If you have other incomes, than employment income at this company, please be sure to mention

those correctly. Errors in the entry, if any, may lead to incorrect deduction calculation.

Ⓒ If your total income is ¥10,000,000 or less, and the total income amount

of your spouse in the same household is ¥1,330,000 or less, please enter

necessary information in the column of exemption for spouse, etc. ※Same spouse information, as the one in the application for (change in) exemption for

dependents, has been typed out, in advance. However, as the application can not be

made, if your total income exceeds ¥ 10,000,000, please erase the spouse information by

double line, in the case.

【Type of Income】Please select 「2: Salary 3: Old-age/Retirement 4: Others 」•For multiple incomes, please enter the amounts in separate lines.

【A～C Column】A column ・・・・ Please indicate your estimated income amount within 2020.

B column ・・・・ Necessary expense amount (2: If salary is selected, please refer to "Method to

calculate employment income total amount", in the back side of the application form.)

C column ・・・・ Please indicate 「Amount in A column」 - (Minus) 「Amount in B column」【Exemption amount for spouse or Special exemption amount for spouse】Please refer to the "Calculation table of exemption amount", in the back side of the application

form.

【Column for non-resident spouse】If an eligible spouse for exemption or a spouse, to whom exemption for spouse is applied, is a

non-resident (Individuals who do not have addresses in Japan, and have not had domiciles in

Japan continuously for more than one year till the present), please put a ○ mark

in the "Non-resident family" column.

Please add remitted amount, etc.

in the"In the same household" column.

H

新(New): insurance contracts concluded on or after January 1, 2012

旧(Former): insurance contracts concluded on or before December 31, 2011

Ｅ

Ｆ

Ｇ

Ｃ

Ｄ

<Note>

・As for the scope of a spouse, to

whom application for exemption for

spouse or special exemption for

spouse is applied, please refer to the

right.

A

B

No Faxed/CopiedForm Accepted

Remarks for tax revisions have been applied to the following two

points since 2020.

1: Handling of basic exemption

(Those, who have other incomes than employment income, are requested to confirm B.)

In accordance with tax revisions, the deductible amount is to be calculated, based on the

description in "Estimated amount of your income" in the B column.

2: Establishment of Amount of Income Adjustment

(Those, whose main employment income exceeds ¥ 8,500,000, are requested to confirm D.)

Though we calculate the exemption amount for the applicable persons, based on ① the application

for (change in) exemption for dependents for 2020, there are some cases, in which our company is

not able to calculate. Please confirm so that no omission is made.

・This certificate includes ＜General＞ and

＜Care Medical Treatment＞ in one sheet.

・In case continuously paid till December,

you are able to mention the estimated

amount as of the end of December.

Ⓔ Deduction for life insurance premiums (It is necessary to enter in the

thick-frame part.）Deduction for life insurance premiums is divided into the three entry columns of General/Care

Medical Treatment/Personal Pension. Please enter, based on the description in the deduction

certificate for insurance premiums at hand.

＜General＞ The deduction certificate for insurance premiums, showing 「For general」, etc., is

applicable. By the way, the attachment of a deduction certificate is not necessary, only when it is

the insurance premium under the old classification and is the payment of ¥ 9,000 or less.

(Please note that some falls under the classification of general, even though the name of insurance

type is 「Pension」.)

＜Care Medical Treatment＞ The deduction certificate for insurance premiums, showing

「For care」, is applicable.

＜Personal Pension＞ The deduction certificate for insurance premiums, showing

「For personal pension」, is applicable.

1,330,000 yen or less(2,015,999 yen or less)

Over 1,330,000 yen(Over 2,015,999 yen)

Required or not to fill inApplication for Exemption for

Spouse

Estimated total amount of your income this year（Your estimated income amount, in case you haveemployment income only and are not subject to

exemption of amount of income adjustment)

10,000,000 yen or less(11,950,000 yen or less)

Over 10,000,000 yen(Over 11,950,000 yen)

Estim

ate

d t

ota

l am

ount

ofy

our

spouse's

incom

e t

his

year

(Estim

ate

d a

mount

of

your

spouse's

revenue in c

ase o

fem

plo

ym

ent

revenue o

nly

)

〇Requested to be filled in

×Not requested to be filled in

×Not requested to be filled in

×Not requested to be filled in

1,100,000

Q1: I have not received “保険料控除証明書 (insurance premium

deduction certificate)” from the

insurance company yet and

cannot submit application forms.

Q7: I do not know if my

dependent’s income exceeds

¥1,030,000.

You cannot apply for deduction for medical expenses in year-end tax adjustment. Please file your final tax return by yourself. Please inquire at your regional tax office for details.

Q8: Can deduction for medical

expenses/tax payment for

Furusato (hometown) be declared ?

？

What if the

following

happens？

Q2: I noticed that I had forgot

to enclose the insurance

premium deduction certificate

after submission of the forms.

Q6: Your family members are

increased after the submission

of an application form and the

declaration content is insufficient.

Please mention the situation at the time of entry in the application.

If the declared content is changed by December 31, Reiwa era 2 (2020), after submission,

please submit the "Report of result content/request for correction for Reiwa era 2 (2020)“

by January 7 (Thu), Reiwa 3 (2021).

We will make the settlement of the excess/deficiency of difference from year-end-tax adjustment calculation

in the payroll of February, Reiwa era 3 (2021).

※In case the e-pay Meisai (Slip) is used, the viewing/printing of

「Report of result content for 2020/request for correction」 is possible in the e-pay Meisai (Slip).

If you have corrections, please submit by January 7 (Thu), 2021.

Please submit the documents, already obtained, and the application by the due date.

Additional procedures can be taken, through the following submission of the documents,

which can not be in time for the due date. When you send those, you need to mention the

"Inquiry No.", "Company name", "Employee ID No.", and "Your name",

as shown in the enclosed notice of this document.

Please submit those, surely attached with the above personal information.

▽Mailing Address▽Year-End Tax Adjustment Center, Payroll Inc.

3rd Fl. Nopporo-ekimae Bldg., 52-8 Nopporo-cho, Ebetsu-shi, Hokkaido, 〒069-8521

▽Attachment method of "Inquiry No.", "Company name", "Employee ID No.", and "Your name"▽Mehod ①: To enclose a memo, showing the personal information

Please enclose a memo, etc., showing the necessary information,

and send it to the year-end tax adjustment center.

Method ②: To wait till year-end tax adjustment results are distributed (viewed)

by our company

Please attach it to the attachment column in the reverse side of the

"Report of result content/request for correction for Reiwa era 2 (2020)", to be sent

to you after year-end tax adjustment, and send it , using the enclosed

"Return-mail envelope".

※ Due date: Surely to reach by January 7 (Thu), Reiwa era 3 (2021)

※ In case using the e-pay Meisai (Slip), please view/print the "Report of result content/request for correction

for Reiwa era 2 (2020)".

Frequently asked question: Special credit for loans relating to a dwelling

－4－

If you apply for special credit for loans relating to a dwelling.

*Please visit our website for details on “Application for Special Credit for Loans Relating

to a Dwelling (and/or extension/remodeling, etc.) of Employment Income Earner”.

I have

purchased

a house in

2019 or

before.

If you purchased a house in 2020, please

file final tax return.

I have anapplication formfor special credit forloans relating to adwelling for 2020.

I have a loan

balance

certificate

for 2020.

Submission

NO

Please consult with your

regional tax office.

NO

Please consult with thefinancial institution who

loaned you.

NO

【To the employees who joined the current company within this year 】In case the persons, who had been given the “Special credit for loans relating to a dwelling” in year-end tax adjustment also in or

before the previous year, changed jobs, etc. within this year (when a salary payer changed from the previous years):

Please submit the “Certificate for special credit for loans relating to a dwelling for 2020 year-end tax adjustment”, issued by

the tax office. ※ The persons, who used the dwelling for residential purpose in or before 2010, are requested to apply for the

issuance of the “Certificate for special credit for loans relating to a dwelling (and/or specific extension/remodeling, etc.) for

year-end tax adjustment” at the tax office, where a final return was filed, and submit the certificate.

If you used a dwelling house for residence purpose in or before 2010, and received “special credit for loans relating

to a dwelling” in or before previous year】If you receive the special credit under the same salary payer (have not changed jobs) this year,

・・・Please circle “有” in the Remarks column.

【If you have joint debtors or you have refinanced your loan】If the above is applicable to you, different computation method will be applied to compute the deduction amount.

Therefore, please describe the following in “Remarks” column in the Application for Special Credit for Loans

Relating to a Dwelling (and/or specific extension/remodeling, etc.) of Employment Income Earner for 2020”.

* If there is no description of the following, we cannot compute your deduction amount properly.

In that case please note that we might contact you for inquiry.

▽If you have joint debtors▽Signatures/Seals of your joint debtors (if they are employment income earners, their company name and address

as well) are required in "Remarks" column in “Application for Special Credit for Loans

Relating to a Dwelling (and/or specific extension/remodeling, etc.) of Employment Income Earner".

Please write “私（連帯債務者）は連帯債務者として、住宅借入金等の残額○○○円のうち、○○○円を負担することとしています(I am responsible for ¥○○○ out of the loan balance ¥○○○ as a joint debtor)”, along with your joint debtors’signature/seal.

* Please write responsible amount or ratio, address, name with seal.

* If the responsible ratio is unknown, please inquire at the tax office where you have filed your final tax return.

▽If you have refinanced your loan, please write as the following example▽Please write “The initial loan balance immediately before refinancing is ¥○○○” in “Remarks” column.

Please use red ink.

Please refer to below.

Please fill in necessaryitems, affix your seal, andenclose in thecertificate envelope.

※Please do not enter "your personalidentification number",even if there isa column for the number in the "Application for Special Credit for Loans Relating to a Dwelling".

※For inquiry, 【Inquiry No.】 is necessary.

■E-mail・・・yeta@payroll.co.jp

■Website・・・http://www.payroll.co.jp/nenmatsu/gensen.htmlOur answers to various questions about year-end tax adjustment are mentioned in FAQ. English answers are also available.

[* Login ID is required to access the website]

ログインID・・・02tax ペイロール 検索 Linked from the top

screen of our website

◆Service Period・・・ Thursday, October 13, 2020 –Fｒｉday, February 26, 2021* Closed on Saturdays, Sundays, national holidays, and year-end/new year (December 29 – January 3)

Regarding questions

Q5: As the documents to be

filled out regarding spouse

have been increased,

how to fill out is not clear.

① For those, who enter the name, etc. of a spouse in the "Application for (change in) exemption

for dependents":

・In case your income is ¥ 9,000,000 or less

You are able to enter a spouse with total income amount of ¥ 950,000 or less.

・In case your income exceeds ¥ 9,000,000

You are able to enter an eligible disabled spouse with total income amount of ¥ 480,000 or less.

② For those, who enter the name, etc. of a spouse in the "Application for exemption for spouse" :

※If no entry is made in this application, exemption for spouse/special exemption for spouse are not acceptable.

・In case your income is ¥ 10,000,000 or less

You are able to enter a spouse with total income amount of ¥ 1,330,000 or less.

・In case your income exceeds ¥ 10,000,000

You are not able to make the application.

Please do not enter the name, etc. of your spouse in this column.

(Even if you enter, it will be out of exemption.)

Q3：What is different between

widow and single parent ?

No Faxed/CopiedForm Accepted

Q4 ：What is the difference between

income and revenue ?

The condition is that both do not have spouses (including common-law ones), and each total estimated

income amount is ¥ 5,000,000 or less. On top of that, each is divided on the following conditions.

Single parent (Applied to both men and women) ⇒ Having a child with gross income amount of ¥ 480,000

or less in the same household

Widow (Applied to women only) ⇒ Divorced from a husband and having dependents, other than children,

or whether the husband is alive or dead is not known

Income is the amount, with necessary expenses deducted from revenue.

In case of employment income only, "Employment income exemption amount",

corresponding to necessary expenses, is set, and differs in each revenue amount.

Please refer to the reverse side of 「Application for Deduction for Insurance Premiums and Application

for Basic Exemption and Application for Exemption for Spouse and Application for Exemption of Amount

of Income Adjustment for 2020」 for details.

Example) Income in case annual revenue is ¥ 4,500,000:

Income = ¥ 4,500,000 - ¥ 1,340,000

(Employment income exemption amount) = ¥ 3,160,000

As for such details, as necessary expenses for other incomes, than employment income,

please make an inquiry to a tax office with jurisdiction over your area.