For items with “※,” choose the relevant answer and circle it.

受付番号
2021 Student ID No.
5
　　　Leave the thick-bordered boxes blank
受
付 /
点
検
完了
前後
一括
前期
のみ (Form R1－②)
　　　 (for use by university’s approvers).

Ｒ
Goes to the university ※115 AY 2020
Report on Family Status from:
1: Family home （ 2: Other residence ）
Annual amount
Current occupation Total employment income Total income other AY 2021 AY 2020 received
Name Age employment
Working from (month/year) (pretax)　(thousand yen) (pretax)　 (thousand yen) （ thousand yen）

Applicant
Scholarship name: Scholarship name:
Lecturer 15 20
Status of scholarship
117
前後半期 Applicant Abdul Rahman Patta 38 JASSO Scholarship
4/2015 received
一括申請 (month/year)
授業料免除 --- 25 30 Monthly( 48 )thousand yen Monthly( )thousand yen
Spouse

Andi Yusnaeni Rahman 36 × 　( 12 ) 　months × 　( ) 　months

Family member other than “Student”

・ (month/year)

Relationship
35 40 Name (Age) School Goes to school
前半期分 School type
4
Child

Kina Kirana Ramdhani R --- category from:

授業料免除 School name (Grade)
(month/year)
45 50 ※121 ※122 4：University/College ※123
↑ Muhammad Rifky Ramdhani R
7 1：National 1：Elementary school 5：College of technology

Student
(Age: ) 2：Public

Child
選択する方を (month/year) 6：Specialized training １：Family home
2：Junior high school college(upper secondary) （２：Other
○で囲んでく 55 60
SDN BTN IKIP Makassar 　(except national)
1 3：High school 7：Specialized training residence）
ださい。 (Grade: ) 3：Private college (specialized)
(month/year) ※131
※129 ※130 4：University/College
65 70 Lana Radinka Ramdhani R 1：National
(4月1日現在） 6 1：Elementary school 5：College of technology

Child
(Age: ) 6：Specialized training １：Family home
2：Public 2：Junior high school college(upper secondary) （２：Other
(month/year) 　(except national)
75 80 SDN BTN IKIP Makassar 1 3：High school 7：Specialized training residence）
(Grade: ) 3：Private college (specialized)
※137 ※138 4：University/College ※139
Simultaneous (month/year) 1：National 5：College of technology
1：Elementary school
application 85 90 (Age: ) 6：Specialized training １：Family home
2：Public 2：Junior high school college(upper secondary) （２：Other
for 1st and 　(except national)
7：Specialized training
(month/year) (Grade: ) 3：Private 3：High school residence）
2nd semester college (specialized)
Relationship ※145 ※146 4：University/College ※147
tuition fee Applicant
Note 1：Elementary school
1：National 5：College of technology
exemption Category (thousand yen) (thousand yen) (thousand yen) (thousand yen) (thousand yen) (thousand yen) (Age: ) １：Family home
2：Public 2：Junior high school 6：Specialized training
Salary/Wage college(upper secondary) （２：Other
or 　(except national) 3：High school
Employment income (Note 1)

7：Specialized training residence）

Application
Executive compensation (Grade: ) 3：Private college (specialized)
Wage of family employee
for first
Pension/Pension for Note 1: Regarding employment income, fill in the amount of annual earnings for the previous year (“支払金額 ” [shiharai-kingaku ] indicated on the withholding tax slip [源泉徴
semester public servants (onkyu) 収票 gensenchoshu-hyo], etc.). Disregard fractions less than one thousand yen.
tuition Unemployment benefits Note 2: Regarding income other than employment income, fill in the amount obtained by deducting necessary expenses from the amount of annual earnings for the previous year.
fee exemption
[Note] * If your simultaneous application for first and second semester tuition fee exemption has been
DO NOT fill accepted, fill in the area outlined with a bold line below of a copy of this form and attach your
Income Status

↑ in or attach
Circle your your signature signature. Please submit the completed copy to the section in charge of tuition exemption of the
Total (Employment income)
desired in the right Student Support Division of the Academic Affairs Department, together with a return envelope to
Commerce/Industry area when
application be used for notification of the screening results of successful applicants, within the application period
Income other than employment

Agriculture/Forestry/Fishery submitting in
type. the first for second semester tuition fee exemption.
semester. My household’s financial status, my family status, my registration status and other application
income (Note 2)

House/land rent
(As of April 1.)
Other miscellaneous income

Interest and dividends documentation reported above have not changed as of the date of application for second semester
Side job, Domestic
piecework
tuition fee exemption.
Support from
relatives, etc.
(Month) (date), (year) Student No.: Name (signature):
Part-time job

Total(other than
employment income)

家族数 独立生計 学力 申請区分 非・課税世帯 辞 退

※ 後半期の状況が前半期分と変更のない場合のみ，本紙のコピーの以下の枠内に署名したものを，免
大 218 221 223 224 225 227
除結果通知用封筒とともに，後半期申請期間内に，学務部学生支援課授業料免除担当窓口へ提出して 0 ： 課税
１：一般
１：一般
ください。 　　　　　↓ ０： 無 ０：不適格 ２：家計
学
　２：家計
３：学力
【注意】
「上記に記載した，私の授業料免除申請に係る家計状況，家族状況，就学状況等は， 本年度 1：非課税
前半期申
後半期分授業料免除申請においても，変更はありません。」 １：該当 １：適 格 ４：留年超過等
３：学力
請時には 認
５：家計支持者死亡
署名をし 　４：留年超過等
ないでくだ
６：被災
年 月 日 学生番号 氏名（署名） 　５：家計支持者死亡
さい。→ 定 ８：被災(激甚災害)
人 □ 10月入学 　６：被災