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If you appoint a tax representative to file tax returns and administer other tax affairs because you do not or will not have an address in Japan,
please prepare “Declaration Naming a Person to Administer the Taxpayer’s Tax Affairs for Income Tax and Consumption Tax” and submit it
to the local Tax Office in charge of the location of your address, etc. at the time you appoint a tax representative or prior to the date of
departure from Japan.

payment place.
locations, etc. than tax
other address and office
Please write if there are any
Please write the place of tax payment and telephone number.
to the tax you will report.
the title and in the text, according your seal.
and” or “and consumption tax” in name and affix
Cross out either “income tax

birth.
your date of
Please write
Please write your

Individual Number.
Please write your
representative.
residence of the tax
address or place of
Please write the

name.
the trade
Please write
affix a seal.
representative and
name of the tax
Please write the

occupation.
your
Please write
tax representative.
occupation of the
Please write the

and the taxpayer.

the tax representative
relationship between
Please write the
residence outside Japan.
please write the address or place of
If you plan to move out of Japan,

representative.
of the tax
telephone number
Please write the
representative.
designated a tax
reason why you
Please state the
from/to Japan.
departure or arrival
(planned) date of
Please write the

For the type of income sourced in Japan, please circle the Please write if you have any income other than the
applicable type of income or describe the content. above or the income type is unknown.

*When you dismiss your tax representative, please submit “Notification of dismissal of tax representative
for income tax/consumption tax”.
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