This form is to be used by the Recipient of Dividends in claiming the relief from Japanese Income Tax and Special Income Tax for Reconstruction under the provisions of the Income Tax Convention.

この届出書は、配当に係る日本国の所得税及び復興特別所得税の源泉徴収税額について租税条約の規定に基づく軽減又は免除を受けようとする場合に使用します。

This form must be prepared separately for each Payer of Dividends (including Person in charge of handling payment of Dividends who prescribed in paragraph 1 of Article 9-3-2 of the Act on Special Measures Concerning Taxation; the same applies below).

この届出書は、配当の支払者（租税特別措置法第９条の３の２第１項に規定する配当の支払の取扱者を含みます。以下同じです。）ごとに作成してください。

This form must be submitted in duplicate to the Payer of Dividends, who has to file the original with the District Director of Tax Office for the place where the Payer resides, by the day before the payment of the Dividends is made.

この届出書は、正副２通を作成して配当の支払者に提出し、配当の支払者は、正本を、最初にその配当の支払をする日の前日までにその支払者の所轄税務署長に提出してください。

This form is to be used by the Recipient of Dividends in claiming the relief from Japanese Income Tax and Special Income Tax for Reconstruction under the provisions of the Income Tax Convention.

この届出書は、配当に係る日本国の所得税及び復興特別所得税の源泉徴収税額について租税条約の規定に基づく軽減又は免除を受けようとする場合に使用します。

This form must be prepared separately for each Payer of Dividends (including Person in charge of handling payment of Dividends who prescribed in paragraph 1 of Article 9-3-2 of the Act on Special Measures Concerning Taxation; the same applies below).

この届出書は、配当の支払者（租税特別措置法第９条の３の２第１項に規定する配当の支払の取扱者を含みます。以下同じです。）ごとに作成してください。

This form must be submitted in duplicate to the Payer of Dividends, who has to file the original with the District Director of Tax Office for the place where the Payer resides, by the day before the payment of the Dividends is made.

この届出書は、正副２通を作成して配当の支払者に提出し、配当の支払者は、正本を、最初にその配当の支払をする日の前日までにその支払者の所轄税務署長に提出してください。